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Mitchell Sand and 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 for Clean Inert Material Disposal <br /> as required by the Colorado Division of Reclamation Mining and Safety <br /> Date: <br /> d Pam , C�oLP. <br /> POFAtrc- ,���- o A)I O <br /> m �r1� <br /> Name of Company,City, State,Zip (please print) Phone Number <br /> P cr.O y5—1�e trw+ee�-f >qL.'Cr-n)�4AQ_r5 <br /> Job Site/Location of Material (please print) <br /> jQ1LjC1,A 677C. k1 10 P X r1r_r a/0Z <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 Comp y Representative (please print) <br /> Date: <br /> AutVrizeJ Company epresentative (signature) <br /> "-tame of Authorized Tr sport Company(disposing above material) (please print) <br /> Authorized Transport Compa y 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 /> Rick Mitchell, Owner (signature) <br />