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Date: <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 Bentonitic Drilling Fluids <br />From Water Well Drilling Only <br />As required by the Colorado Division of Reclamation Mining and Safety <br />l 6 Al /i <br />L 4Vwt Gl.02(S7 1 / 7800 b 2Z` kg" <br />Name of Drilling Company, City, State, Zip (please print) Aivrzo2•4 / • god 7/ <br />5747-6 Cm°f7-42_ <br />Well Location/Job Site of Drilling Fluid (please print) <br />- - Ll 4 , oil vD <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 Regulations <br />and State of Colorado Regulations. <br />0 ; v"•. IAA L I <br />Authorized Drilling Company Representative (please print) <br />Authorized Drilling Company Representative signature <br />L ALA Gka-∎5 /ENSGry <br />Name of Transport Company disposing of above material (please print) <br />S; ILL 1 <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Rick Mitchell, Owner <br />Date: Sl / C / it <br />Date: `E/ 1 L / 1 I._ <br />Drilling Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />