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Mitchell Sand and Gravel <br /> 48580 Hwy 36 - P.O. Box 10, Beynett, CO 80102 RECEIVED <br /> 303-644-4102 303-870-4260 cell <br /> MAR 2 6 2018 <br /> A disabled American veteran owned company <br /> DIVISION OF RECLAMATION <br /> Authorization Form as required by the Colorado Division of RANKIN SAFETY <br /> Mining and Safety for Disposal of Ground Water and/or Hydrovac Slurry Water <br /> Date / g <br /> xrtia*yjci <br /> Name o Generator, City. State, Zip (please print) <br /> 3 —/�w S 41-trOri7L- C® . 803j/ <br /> Generator's Location/Job Site (please print) <br /> • 3/ 4A. - <br /> Name/type of Mate I/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 /> 'sen <br /> p <br /> Authorized Generator Company• Re rep tative (please •rent) <br /> •r'zed - - .r Company Repre �n ative ignature <br /> -vino Dar— <br /> Name <br /> acName of Transport Company disposing of above material (please print) <br /> rntr MCD 147 vti�-dl <br /> Transport Company Representative (please print) <br /> Date:3/9 <br /> Transport Company Representative signature <br /> Fluid Disposal/Destinatioi • itchell and and -avel Pits Bennett. CO 80102 <br /> ,11)1° <br /> Ric - Mitchell. Owner <br />