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Mitchell Sand and Gravel <br /> 48580 Hwy 36-P.O.Boa 10, Bennett, CO 80102 Date: " /3—2-1 <br /> 303-870-4260 (cell) <br /> —A disabled American veteran owned company— <br /> Authorization Form as required by the Colorado Division ofReclamation Mining and Safety <br /> for Disposal of Hydraulic Directional Drilling Mud, or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> Stone Crafters <br /> Name of Generator or Drilling Company, tate, Zip (pl <br /> 2605 W 8th Ave, Denver, eolorado'MM4 <br /> Material's Location/) b Site (please print) <br /> Granite WQater <br /> Type of Material Disposing (please print) <br /> Generator or Drilling Company guarantees that all material to be disposed of is both non-hazardous and <br /> non-harmful to soil andlor crops,etc.pursuant to all applicable Federal and State of Coloradoegulations.All <br /> material is"inert material" as defined as"non-water-soluble and non-putrescible solids together with such minor <br /> amounts and types of other materials,unless such materials are acid or toxic producing:as will not significantly <br /> affect the inert nature of such solids. The term includes,but is not limited to,earth,sand,gravel,rock,concrete <br /> which has been in a hardened state for at least sixty days,masonry,asphalt paving fragments,and other inert solids". <br /> In adverse weather,contact me first:tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br /> Authorized Generator or Drilling Company Representative: Date: L/ <br /> Brian Tucker z <br /> (please print name) (signature) <br /> Enviro-Vac, INC <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above material: Date: t9 /k12 <br /> (please print name) (signature) <br /> Date: <br /> ��3 2 <br /> Ricky W. chell, Owner/Operator <br />