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Mitchell Sand and'Gravel Receiveo <br />48580 HViy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 -644 -4102 303- 870 -4260 cell DEB 14 2014 <br />Authorization Form for Clean Inert Material Disposal Mlningg��a'nation, <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: r �0 <br />H(rj�t '�� C 0 80 401 X33° c £3a - 10 9 u <br />�a 1 hhln' e of (: ontpany, Cite, State, 'Lip (please print) Phoiic Ntimber <br />Job Site /Location of Material p ease print) <br />fy�C��u6S �SZWL7 <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 Coltii-ado Regulations. <br />3. Only the transport company authorized below is allowed todump at this site. 's <br />4. Material may not be brought into this site on rainy or snom-j- days, when mud could <br />get tracked or carried onto Highway 36. <br />L Au Representative (please print) <br />-'IL Date: 3 3 <br />'`;lYitl- --ired Companv`Representative (signature) <br />I-Wte_oo Authorized Transport Company (disposin(, above material) (please print) <br />Authorized Transport Company Representative (please print) <br />Date: <br />Authorized Transport Company Representative (signature) <br />Clean Inert Material Disposal /Destination: Mitchell Sand and Gravel Pits. Bennett. CO 80102 <br />r- <br />Rick Mitcliell, Owner (signature) <br />