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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-zti-ll Renegade Oil & Gas Company <br /> 6155 S Main St Ste 210 <br /> Aurora, CO 80016 <br /> Name of Drilling Company, City, State, Zip (please print) <br /> lACt tf l.ounAao 1.3's 5tcrroa 331-65,R01, Nuo uof (cv#Il?, CbPo <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> It\,)ai&R .9EV IDAILLIA4 .1)tr - ilo 1: rb riE To rzotilR60,1b <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 /> Authorized Drill' Co any : presentative (please print) <br /> r Date: ,-' '24"- 17 <br /> Authorized Drilling Compa/Representative signature <br /> blw,EP SE vtr.2S <br /> Name of Transport Company disposing of above material (please print) <br /> Transport Company Representative (please print) <br /> 7 (/�G %-t— Date: "Z`117 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> ///, <br /> .,ik "`r f <br /> Rick Mitchell, Owner <br />