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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: 5-7,4 '1`1 <br /> ZAD6 Ou.+.6lSWrirogY, IX (0155 5 fAAASi Siam kcor Co ?Oa, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> gtRvS ATE,.SZ-1 EtTicr.1U :TSS,IZLV 44041iDE Catr41Y,et,olAco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> IMIT-46657 1:64A rW lD - 140 E'ACASfi To9.DCA¢Eor4S <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 /> eowsx <br /> Authorized Drilling m Representative (please print) <br /> A-, <.. Date: 5-ZL1.1`1 <br /> Authorized Drilling Co any Representative signature <br /> 1\-If /Flew 6Eg3hkk5 <br /> Name of Transport Company disposing of above material (please print) <br /> -cri Wei <br /> Transport Corn any Representative (please print) <br /> a t il�(,fi Date: 5-74-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett, CO 80102 <br /> ,,- --/ . _ ,Ari -' <br /> Rick Mitchell, Owner <br />