Laserfiche WebLink
Mitchell Sand and Gravel <br /> l rG ' <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 /> From Water Well Drilling Only <br /> As required by the Colorado Division of Reclamation Mining and Safety <br /> Date: /0/0,> <br /> a,AJrr C <br /> I/YDRD Ri�.$50xuj2oil:S /3®) CR 1 S rr Lcz ;,v Co-- 9C:)6,)/ <br /> Name of Drilling Company, City, State, Zip (please print) <br /> O Lb e. gi--- (f G-LelA Ci>e CO/9V, L---4v6LilCICCO ' <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 4 710 -,-/-/ (4e---- 6:117"1 I/t--L1 / <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 CDO T. <br /> ci 5c-' DeG e . . <br /> Authorized Drilling Company Representative (please print) <br /> 2z.- <br /> �% <br /> / ��� Date: /0-21"1 <br /> G orized rt i-fi-ng Company Representative signature <br /> k(d ee_60NCLS <br /> Name of Transport <br /> FCoompan�y disposing of above material (please print) <br /> tlathltU 15 .7::L{ C(e <br /> Transport Company Representative (please print) <br /> i ' 'a : Date:iN.2_,( i --4- <br /> ....- <br /> Transport ompanyal•resentative signature <br /> Drilling Fluid Disposal/Destination. itchell Sand and Gravel Pits, Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />