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FROM a1obal Underground Corp. <br />Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303 - 870 -4260 cell <br />Authorization Form for Disposal of Water Based Beatunitic Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety. <br />Date: /O - f - /�. <br />C(L t8At UMptr 411 D <br />Name of Drilling Company, City, State, Zip (please print) <br />c{. o CC La- eft <br />OL P R4 , <br />-f. <br />Z <br />Well Loeatiun/Job Site of Drilling Fluid (please print) <br />Name /type of Material/Fluid (please print) <br />Drilling Company guarantees that all material to be disposed of, is both non - hazardous and <br />non - harmful to soil and/or crops, etc., In accordance with all applicable Federal and State <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />Meat aW5 <br />Authorized Drilling Company Representative (please print) <br />uthorized Drilling Company Representative signature <br />* 1,Ja +et• S erg r <br />Name of Transport Company disposing of above material (please print) <br />c <br />port Company epreserttative (please print) <br />Transport Company Representative signature <br />• <br />Drilling Fluid Disposal/Des <br />C80,0001 8 2012 12: 45lST. 12: 44FHo. 7500000206 F 1 <br />DDWATER PAGE 01/01 <br />Rick Mitchell, Owner <br />Date: /Q --g- /.2. <br />Date: d - �"1 <br />