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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 -IL-II <br /> ‘dE.GAK 011.45CotirogY, (.LG 6I 55 5 Pon►S i GIE Zt O A¢pip tea, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> 161Rv6[AT6 SZ-1 Secticol 32 111S,ill•V 40144x& CotriTY,etno,Aoo <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> ping- 11:Ltu c rW IP 1401StroSueS To 41abrizZor45 <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 /> GoWPW I hIGJt's <br /> Authorized Drilling C4..Representative (please print) <br /> Date: 5 I6"(1 <br /> Authorrzed Drillli/i��ng Cepresentative signature <br /> kir <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wewtos <br /> TransportCompanyRepresentative (please print) <br /> I��1"( / Date: 5-14 17 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> ,,,, ',..;,,‘". <br /> Rick Mitchell, Owner <br />