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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: 1'11) <br /> t4i.GADC Dtt-}644KrMY, (.LG 6i56 5 ti 7-to Atsco Co $001 <br /> Name of Drilling Company, City, State, Zip (please print) <br /> girwSnr SZ-I Siaief43z ,` S,IZL* 144114+oE Cots Y,einetoco <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> p'fER-&EP fittWtl4 fiI v IP - 0 EYV Tv NPIZW.A¢bor45 <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 /> e0t.A140 I t 4J5 <br /> Authorized Drilling C p 'epresentative (please print) <br /> L� t Date.: 1.1D-11 <br /> Authorized Drilling Comp. Representative signature <br /> it OLFIEL425Emas <br /> Name of Transport Company disposing of above material (please print) <br /> TM WEt.1.441 <br /> Transport Company Representative (please print) <br /> 1C4t/\LUC <br /> Date: 1.1°-ll <br /> Transport Company Representative signature <br /> Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits,Bennett,CO 80102 <br /> Rick Mitchell, Owner <br />