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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-Z`r'Il <br /> F 010-I46CbttrogY, LLC. 6)I55 5 MAtaST 6rZto Aviz Co $Oplfi <br /> Name of Drilling Company, City, State,Zip (please print) <br /> girwSTAr SZ-1 Sinal u ,`tSs,DO.) 4904106.Cowry,Caton/ <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> \\Va.aese.9 itWa411W tP -1\10 r1cfoStR&Tv {pRbeAldortS <br /> Name/type of MateriaUFluid (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 /> Eot Pao i tt4Alti <br /> Authorized Drilling C pan epresentative (please print) <br /> i <br /> ,./%4/t/.7- �. Date: 5"L�I-1�1 <br /> Authorized Drilling ComL,-y.Representative signature <br /> iv 00E142 ,1d5 <br /> Name of Transport Company disposing of above material (please print) <br /> TM Wit <br /> Transport Company Repr entative (please print) <br /> • <br /> / om—' <br /> A Date: 5'Z'1'11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination:Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> ,,,,, / <br /> Rick Mitchell, Owner <br />