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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: I 01,.1_-7 I l l <br /> Z CoQQ, "TEcN,s()Losi Fs - m nQ.G4,i1, WC. t31i o Sc. <br /> Name of Generator,City,State,Zip (please print) <br /> A u R o2Ak Cn, E K1;nt TU(icy Avdr BUCKLE/ QD <br /> Generator's Location/Job Site(please print) <br /> BEA ro NI CTE DR-x.Lt-t n1 6 flex v o <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 /> Authorized Generator Company Representative (please print) <br /> E3 ck:. Com,..&- Date: I CS / - 7 / 17 <br /> Authorized Generator Company Representative signature <br /> 00J) 4/617 Sayicc t 11 C. <br /> Name of Transport Company disposing of above material (please print) <br /> Cid/A /C/(C7 <br /> Transport Company Representative (please print) <br /> a,Q� �di Date: /0/D--7 / 17 <br /> T ,' Company Representative signature <br /> Fluid Disposal/Destination:Mitchell Sand and Gravel Pits.Bennett,CO 80102 <br /> Rick Mitchell,Owner <br />