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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 as required by the Colorado Division of Reclamation <br />Mining and Safety for Disposal of Ground Water and/or Hydrovac Slurry Water <br />Date: <br />A -to (41,cky /94.0 <br />Name of Generator, City, State, Zip (please print <br />k&i3 (s <br />Generator's Location/Job Site (please print) <br />/--/Vog0 V27 -C (,,C)4--774 <br />Name/type of Material/Fluid Disposing (please print) <br />Fr ,( civ <br />Ab -(A <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 />c y /14-7N DA/ L. - r) ja i o(Ct— k <br />Authorized Generator Company Representative (please print) <br />Date: j e?%///5 <br />uthorized Generator Company Representative signature <br />Name of Transport Company disposing of above material (please print) <br />Transport Company Representative (please print) <br />Date: /e),///7/5 <br />Transport Company Representative signature <br />Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett, CO 80102 <br />Rick Mitchell, Owner <br />