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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 for Clean Inert Material Disposal <br /> as required by the Colorado Division of Reclamation Mining and Safety <br /> Date: l%(3 Za 1 �' <br /> K l e a '�3<o Kltw►c4 s Cc) ?c',-/63 3d 3 - -y'-( 7 5— <br /> Name of Company, City, State, Zip (please print) Phone Number <br /> 1" `4-'().5 c,% all c+Y�l e <br /> Job Site/Location of Material (please print) <br /> M6 AN,C1MaN' comm,06 <br /> Name/type of Material (please print) <br /> 1. Only inorganic inert materials may be dumped at this site. Dumping of any type of <br /> contaminated material or soils is not allowed.This includes petroleum products, chemical <br /> products, asbestos,and lead-based paints. <br /> 2. Said Company guarantees that all Clean Inert Material to be disposed of,is both <br /> non-hazardous and non-harmful to soil and/or crops,etc. in accordance with all applicable <br /> Federal and State of Colorado Regulations. <br /> 3. Only the transport company authorized below is allowed to dump at this site. <br /> 4. Material may not be brought into this site on rainy or snowy days,when mud could <br /> get tracked or carried onto Highway 36. <br /> NA„;i��,c,�� <br /> Authorized Company Representative (please print) <br /> Date: r'4/3 1; 2e' i 7 <br /> Authorized Company Representative (signature) <br /> Kt Po.:) <br /> Name of Authorized Transport Company(disposing above material) (please print) <br /> flit d 1 tOat:'j <br /> Authorized Transport Company Representative (please print) <br /> WI) dj Date: �/y 'L 2.C4 <br /> Authorized Transport Company Representative (signature) <br /> Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> Rick Mitchell, Owner (signature) <br />