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Mitchell Sand and Gravel <br />48180 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 for Clean Inert Material Disposal <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: C9 <br />Name of Company, City, State, Zip (please print) Phone Number <br />Job Site /Location of Material (please print) <br />Go vc.qKT& ,q ! i <br />game/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 />\ V'k I Ulam? °C rv, <br />Authorized C6mipuy Repres tive (please print) <br />Authorized I>Qmpany Repres"tative (signature) <br />Name of Authorized Transport Company <br />IN <br />Date: / c <br />(disposing above material) (please print) <br />Authorized Transport Compa Representative (please print) <br />Bate: 1' c_ � e= <br />Authorized Transport C mpany Representative (signature) <br />Clean Inert Material DisposaVDestination: Mitchell Sand and Gravel Pits. Bennett, CO 80102 <br />/'��z4t�44& <br />Rick Mitchell, Owner (signature) <br />