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Mitchell Sand and Gravel J <br /> 48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 6 1 �; <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 /> From Water Well Drilling Only <br /> As required by the Colorado Division of Reclamation Mining and Safety <br /> Date: j* <br /> Z/L /i C <br /> f-7� yPi-;c A %Le6,'C_c .5 /3 Z.),7 ? C./� /v �FT ,Vre,L. LU., P-C4:2, <br /> / Name of Drilling Company, City, State, Zip (please print) <br /> C - 4PFL /Y/ _c_ CEe-t y — XRk3POE r C �; <br /> �- . l.-ua <br /> P <br /> Well Location/Job Site of Drilling Fluid (please print <br /> 7?(-.- >-= ,l/' /),(-,t/ . T/ y/ <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 Regulations <br /> and State of Colorado Regulations. If adverse weather(rain,snow), please contact nie <br /> first: tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br /> 1-^ 7 ) j <br /> Authorized Drilling Company Representative (please print) <br /> 7,e �_- C Date: - /(1 Cr, <br /> X.ut 6rized D , pany Representative signature <br /> Name cif Transport Company disposing of above material (please print) <br /> p / <br /> ----c__,-- (-_,.., 7c-C e,-- <br /> Transport Company,Representative (please print) <br /> �j� �j /, <br /> z , - _,. �--- Date: / `'�2 <br /> ransporf fompany Representative signature <br /> Drilling Fluid Disposal/Destina ion: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> A.:-.;;‘-"Ar--26V41,1"" <br /> Rick Mitchell, Owner <br />