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Date: <br />5C <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 />as required by the Colorado Division of Reclamation Mining and Safety <br />649G- Jpia ' <br />Name of Drilling Company, City, State, Zip (please print) <br />7 - � <br />Pig*? C ' lvc! --1J f <br />Well Location/Job Site of Drilling Fluid (please print) <br />Sea 8 /cte Sl f� S/ l� ani 2€4104/ <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 bf the Colorado Oil and Gas Conservation <br />Commission. <br />rzl “'675 <br />Authorized Drilling Company Representative (please print) <br />Authorized Drilling Com s : ny Representative signature <br />T� ti)(4f6►- Set-vi <br />Name of Transport Company disposing of above material (please print) <br />Date: Oa'-><I /a- <br />Transport Company Representative (please print) <br />Date: 8 /a I l -- <br />Transport Company Representative signature <br />Drilling Fluid Disposal/Desti4"•n: Mitchell Sand and ravel Pits Bennett CO 80102 <br />a <br />Rick Mitchell, Owner <br />f 5 C'05-/- 1dck <br />