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Mitchell Sand and Gravel <br /> 48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br /> 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: ` 1 <br /> Name of Drilling Company, City, State,Zip (please print) <br /> A5?0��ti 4a G C_o <br /> Well Location/Job Site of Drilling Fluid (please print) <br /> Q tq m u-.0 Y/�r. /yl'f7z' A'S l-7f0 <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 me <br /> first: tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br /> s' 1 9 A t <br /> Authorized Drilling Company Representative (please print) <br /> 5 —_ �/ � b Date: 7 <br /> Authorized Drilling Company Representative signature <br /> Name of Transport Company disposing of above material (please print) <br /> J � N'lLr <br /> Transport Company Representative (please print) <br /> '�4� Date: 7l1n//2ol' <br /> Transport Company Representative signature <br /> Drilling Fluid DisposaUDesti ion: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> Rick Mitchell, Owner <br />