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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: 1 '1D - n <br /> if,44ft.itiDE 0,06ASCZINJY, Lit 6155 &pi Sr,51,210 Aum co $oo,c, <br /> Name of Drilling Company, City, State, Zip (please print) <br /> Vol'SIUE 5Eu'll ort {(' ,T7.5 , 074),Nom Coin, Coux4sDa <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> 1,•6It DPsED P4u.44( 1 wIv -11 o 64116vrr.Tc .\1P oc49to45 <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 /> It <br /> Authorized Drilling C mpa Representative (please print) <br /> Arvl Date: 1 '10'11 <br /> Authorized <br /> -D-r►iillliing Co any Representative signature <br /> NW' VtifLt.v 56iblicEs <br /> Name of Transport Company disposing of above material (please print) <br /> IoM Oi.u.MP41 <br /> TransportCompany Rep sentative (please print) <br /> iit L ` ' Date: 1 -l D-11 <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> r `,e/7 <br /> Rick Mitchell, Owner <br />