Laserfiche WebLink
k� <br />Mitchell Sand add Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303- 870 -4260 cell <br />A disabled American veteran owned company <br />Authorization Form as required by the Colorado Division of Reclamation <br />Mining and Safety for Disposal of Ground Water and /or Hydrovac Slurry Water <br />Date: 6 f <br />Name of <br />, City, State, rp (please print) <br />17,Y":7 G, y c% / me 5 1L <br />Generator's Location/Job Site (please print) <br />C- le-r o cXLd <br />Name /type of Material/Fluid (please print) <br />Generator guarantees that all material to be disposed of is both non - hazardous and <br />non - harmful to soil and /or crops, etc. pursuant to all applicable Federal and State <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />t `LTC4c - � t..J <br />Authorized Generator Company Representative (please print) <br />_...__ Date: <br />uthorize Generator Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />/1lLk h��L_tj <br />Transport Company Representative (please print) <br />Date: <br />ransport CArnpany Representative signature <br />Fluid Disposal/Destination: <br />Rick Mitchell, Owner <br />6 'f <br />mow. <br />d <br />tr :. <br />r <br />