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Mitchell Sand and Gravel, <br /> 48580 Hwy 36 -P.O. Box 10, Bennett, CO 80102 <br /> 303-644-4102 303-870-4260 cell <br /> A disabled American veteran owned company <br /> Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br /> as required by the Colorado Division of Reclamation Mining and Safety <br /> Date: 5 .2-11 <br /> a&E.cikx O4ASWrirogi, LIL 056 S PAAST 1rIto AmorA Co $Qplt <br /> Name of Drilling Company, City, State,Zip (please print) <br /> giWv6tATe diad 37 ,T s,VWJ QRAPbtaos tarm',CW04)0 <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> War-456P'�i Ltu rW tP - 140 e'1cioe.AS i To1,1411VDCAESOPI5 <br /> Name/type of Material/Fluid (please print) <br /> Drilling Company guarantees that all material to be disposed of is both non-hazardous <br /> and non-harmful to soil and/or crops,etc. pursuant to all applicable Federal and State <br /> of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br /> Commission. <br /> Authorized Drilling Co an epresentative (please print) <br /> 5-Z'�1 <br /> Z- r Date: <br /> Authorized Drilling Company Representative signature <br /> IV VI> EW.JGFLItLS <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wem+ s <br /> Transport Company Represntative (please print) <br /> Date: 5.2'Il <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102• <br /> • <br /> Rick Mitchell, Owner <br />