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- Mitchell Sand and Gravel <br />REC- i-v 48580 Hwy 36 - P.O. Box 10 Benn ett, CO 80102 <br />303- 644 -4102 303 - 870 -4260 cell <br />� r� _ <br />FEB 14 2034 <br />horization Form for Clean Inert Material Disposal Division fl,R. <br />a.; r p n of R.,c �attl,, <br />d by the Colorado Division of Reclamation Mining and Safety <br />�l) B &x .3j� <br />,x -RRsvM <br />�a 3a <br />Name of Company, City, State, Zip (please print) Phone Number <br />i7. , J - '`fie ��► r t' o � ,/ � � O �c �,.. -, c-,. -�- 1 `7 _ ! <br />Job Site /LocAtion of Material (please print) <br />-9 /A/ L{ %�q_r'eR A1uIQ CORN SQi C Lt—, -r/Af4 < <br />Name /type of Material (please print) <br />1. Only inorganic inert materials may be dumped at this site. Dumping of any type of <br />contaminated material or soils is not allowed. This includes petroleum products, chemical <br />products, asbestos, and lead -based paints. <br />2. Said Company guarantees that all Clean Inert Material to be disposed of, is both <br />non - hazardous and non - harmful to soil and /or crops, etc. in accordance with all applicable <br />Federal and State of Colorado Regulations. <br />3. Only the transport company authorized below is allowed to dump at this site. <br />4. Material may not be brought into this site on rainy or snowy days, when mud could <br />get tracked or carried onto Highway 36. <br />Authorized Company Representative (please print) <br />Date: I t, — 1 .2�, <br />Authorized Company Representative (signature) <br />Name of Authorized Transport Company (disposing above material) (please print) <br />Authorized Transport Company Representative (please print) <br />Authorized Transport <br />Representative (signature) <br />Date: `o - 1 J -- I -), <br />Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits Bennett CO 80102 <br />Rick Mitchell, Owner (signature) <br />