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Date: /Z, <br />Authorization Form for Disposal of Water Based Bentonitic Drilling Fluids <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Carrizo Oil & Gas <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 />Name of Drilling Company, City, State, Zip (please print) <br />WEP 4- 28- 11 -3 -64 <br />Well Location/Job Site of Drilling Fluid (please print) <br />Fresh Water Drilling Mud <br />Houston, TX 77002 <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 />uthorized Drilling Compa ' ep <br />ransport Company <br />orized drilling Company Representative signature <br />a/U1/(5 M- 5>5c <br />Name of Transport Company dispoyfng of abo material (please print) <br />esentative (please print) <br />native (please print) <br />T . nsport Company Representative signature <br />Drilling Fluid Disposal /Desti tion: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner <br />Date: <br />Date: <br />