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Mitchell Sand and Gravel RECEIVED <br /> �� i 48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 �1 <br /> 303-644-4102 303-870-4260 cell <br /> A disabled American veteran owned company DIVISION OF RECLAMATION <br /> (QqQ--13 ( P Y � MINING AND SAFETY <br /> Authorization Form for Clean Inert Material Disposal <br /> as required by the Colorado Division of Reclamation Mining and Safety <br /> Date: lkh <br /> C%600/A.-jo Ce/y1 1 7;0C. <br /> Name of Company, City, State,Zip (please print) 9t zf©/ Phone Number <br /> igrg'� .5CROO c.5 P-- B/—nV4�7'T <br /> Job Site/Location Toff Material (please print) <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 /> �► GUI V (_'A-w <br /> Authorized Company Representative (please print) <br /> Date: ! 1 � <br /> Authorized Company R resentative (signature) <br /> V Cv?LAN n C,o6 a?'myG`( � NC, - <br /> Name of Authorized Transport Company(disposing above material) (please print) <br /> Authorized Transport Company Representative (please print) <br /> Date: <br /> Authorized T nsport Company Representative (signature) <br /> Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br /> Rick Mitchell, Owner (signature) <br />