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Mitchell Sand and Gravel <br /> 48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br /> 303-644-4102 303-870-4260 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: , /v9.3/ O/8 ,SE-•%- /0 -/..? 5`f <br /> (/) C 4i?r a <br /> .r 1 14,42oRa/67 <br /> Name of Generator, City, State, Zip (please print) Yot)ii <br /> 3.30 / e co; ft) t ieo a Co goo/( <br /> Generator's Location/Job Site (please print) <br /> Name/type of Material/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 /> &ate 7 j is/t <br /> Authorized Generator Company Representative (please print) <br /> Date: JA.23//B <br /> Authorized Generator Company Representative signature <br /> Lill-,g0 C, ZVc <br /> Name of Transport Company disposing of above material (please print) <br /> s 459° <br /> Transport Company Representative (please print) <br /> Date: <br /> Transport Company Representative signature <br /> Fluid Disposal/Destination: Mitch- Sand and Gravel Pits Bennett, CO 80102 <br /> f <br /> Rick Mitchell, wner <br />