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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: 5-5"n <br /> E.(At.c OIL e.644b? r ►tY, 114_, (Mg 5 fAtol ST GICZIO Atsom Co &A(s <br /> Name of Drilling Company, City, State, Zip (please print) <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1;6-414 rw tp -140 F-YgoSultS To 4bCaaEorM5 <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 /> eowmty I Aqts <br /> Authorized <br /> Drilling omp Representative (please print) <br /> ll <br /> Date: 5-5 11 <br /> Authorized Drilling Company Representative signature <br /> Name of Transport Company disposing of above material (please print) <br /> c4 Wei <br /> Transport Company Repres 4tative (please print) <br /> Date: 5-5-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />