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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 />3 Soci riur.)f) L. L C <br />F'r- o PtAiY c .. <br />Name of Generator, City, State, Zip (please print) <br />Generator's Location/Job Site (please print) <br />Name/type of aterial/Fluid 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 />JEIT C-,\Pn. <br />Authorized Generator Company Representative (please print) <br />Date: <br />Author' ' ed Generator Company Representative signature <br />01-\ \O'N S <br />Name of Transport Company disposing of above material (please print) <br />toamS <br />Transport Company Representative (please print) <br />Transport Copany Representative signature <br />Date: <br />Fluid Disposal/Destinatiow itchell Sand and Gravel PitsBente CO 80102 <br />l <br />Rick Mitchell, Owner <br />