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Mitchell 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 and Safety for Disposal of Ground Water and/or Hydrovac Slurry Water <br />Date: 6/16/2017 <br />Mid America Pipeline Const. Int.,12115 E Admiral PI Tulsa ox 74116 <br />Name of Generatar, Cite, State, Zip (please print) <br />5600 E 56Th Ave Denver CO, <br />Generator's Location/Job Site (please print) <br />City water,Chydro Test New Const.), /Soil Cl_2 wet- 5600 E 56th Ave Denver Co <br />Name/type of Material/ 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 />Esteban Galvan <br />Authorized Generator Company Representative (please print) <br />rz&a -�L Date: 6/22/2017 <br />Authorized Generator Cs)mpany Representative signature <br />j,LLC. <br />Name of Transport Company disposing of above material (please print) <br />r G1f!/1 IGr" <br />Transport Company Representative (please print) <br />Date: <br />Tr yprt Company Representative signature <br />V <br />Fluid DisposaliDestination. Mitchell Sand and Gravel Pits Benne C4 80102 <br />Rick Mitchell, Owner <br />