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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 />r(,2 -61Y <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: X, q 40 c-1426. <br />T r--TREv s 4-' n.) Co . m)0.5 <br />Name of Generator, City, State, Zip (please print) <br />aQ t meber BLS -}o c�-d tmtiE404 1/ C,fl. <br />Genera or's Location/Job Site (p ease print) <br />4_LpOC i'"1a.0 5�4viti6$ <br />Name/type of Material uid Disposing (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 of <br />Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. If adverse weather (rain, snow), please contact me first: tracking mud <br />from the pit onto Highway 36 is not permitted by CDOT. <br />/Z.4" 6:C/e4, <br />Authorized Generator Company Representative (please print) <br />orized Generator Company Representative signature <br />L' <br />Date: /C9 -/Z - /5" <br />Name of Transport Company disposfing of above material (please print) <br />6s''/',4t /sea <br />Transport Company Representative (please print) <br />L <br />/tel Date: /a -/ 2 -1 rd <br />Transport Company Representative signature <br />Fluid Disposal/Destination: M. ell Sand and Gravel Pits Bennett, CO 80102 <br />Rick Mitchell, Owner <br />