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IYiitcheli Sand and Gravel <br />48580 Hwy 36 - P.O. Boz 10, Bennett, CO 80102 <br />303-644-4102 303-8704260 cell <br />A disabled American veteran owned company <br />Authorization Form as required by the Colorado Division of Reclamation <br />Mining sod Safety for Disposal of Ground Water and/or Hydrovac Slurry dater <br />Dale: <br />ane of Generator, City, Mate, Zip (please print) <br />I' Z� % <br />Location/Job Site (please print) <br />Name/type of Material/Fi d (please print) <br />Generator guarantees that all material to be disposed of Is both non-6aardous and <br />non -harmful to soil and/or crops, etc. pursuant: to all applicable Federal and State <br />of Colorado Regulation$, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. r '� <br />Authorized Generator Company Representative (please print) <br />f <br />�--- Date: <br />thorize Generator Company Representative signatum <br />0 �LQ a 7E2 S60 0 e c 11 <br />Name Df Tfransport[C�ompany disposing of above material (please print) <br />_ rf _fl h Al cl'je <br />Transport Company Representative (please print) <br />Date: <br />T port Company Representative signal= <br />Fluid Disposal/Destination: Mitchell Sand and Gravel Pits. Bennett, CO 80102 <br />Rick Mitchell, Owner <br />