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Mitchell Sand and Gravel l 6 / <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 Hy-drovac Slurry Water <br /> Date: ?Xi/7 <br /> �()1 (OSS ,n /7 �J , g <br /> 1 1 <br /> Name of Generator, City. State, Gip (please print) <br /> 000-% iIS % s/x4d A7 , <br /> Generator's Location/Job Site (please print) <br /> 1 '� <br /> /�/Yeo 1/A'e ,, 1�,1k'k �y6,/` <br /> Name/type of Materi4l/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 /> /41ii, /76:6-' <br /> Authorized Generator Company Representative (please print) <br /> 7 Date: ?///7 <br /> Authorized Generator Company Representative signature <br /> l <br /> _1(14,e 4.i.Z- foc4,, <br /> Name of Transport Company disposing of above material (please print) <br /> f.4//F-: <br /> Transport Company Representative (please print) <br /> Date: <br /> Transport Company Representative signature <br /> Fluid Disposal/Destination: Mitchell Sand and Gravel Pits Bennett. CO 80102 <br /> "1 ...... Aaig-ZL...--- <br /> Rick Mitchell. Owner <br />