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Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Boz 10, Bennett, CO 80102 <br />303-644.4102 303-870-4260 cell <br />A disabled American veteran owned company <br />Aatborizadon 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 />� Tac-. e c OG+Z <br />Name of Genera or, City, State, Zip (please print) <br />Lam, ,rh 4 - <br />Generator's Location/Job Site (please print) <br />I"'vd <br />Name/type of MatMal/Fluid (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 <br />of Colorado Regulations, including Rule 907 of the Colorado Oil and Gas Conservation <br />Commission. <br />A;,- k, -N LIM <br />Authorized Genefator Company Representative (please print) <br />Date: <br />Authorized Generator Company Representative signature <br />_ 0<3 (,Cfv.7EC <br />Name of Transport Company disposing of above material (please print) <br />/!A 1c ke <br />Transport Company Representative (please print) <br />61�/7 <br />w Date: , (o j to I <br />Tq�Poft <br />Company Reptescntative signature <br />Fluid Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett CO 80102 <br />Rick Mitchell, Owner <br />