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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 -`i- 11 <br /> •Zsiti c D1t.i-G4.5WKrogY, Ix (0175 S MaaST Grc210 Co tam, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> gitv6rrr SI-1 Same)3z ,-TSs,V- J kkooktice &tral.,CbtoleAco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> I\\p'rea. CRtwa4 rwty - 140 E-YgoSuRfi Tv 14,peocaesot45 <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 /> Authorize/tri <br /> ' gCo any R resentative (please print) <br /> A47,-;/.----7/ Date: 5-y-11 <br /> Authorized Drilling Compan Representative signature <br /> lkrf aUIEUP s ,W5 <br /> Name of Transport Company disposing of above material (please print) <br /> TM Qe1.14014 <br /> Transport <br /> C Company Representative (please print) <br /> Li/I id/I& -I Date: 5-4-n <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> .-2:::: .A1-* <br /> Rick Mitchell, Owner <br />