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Plr /.12C <br /> �7 <br /> Mitchell Sand and Gravel <br /> 48580 Hwy 36-P.O.Bog 10, Bennett, CO 80102 Date: <br /> 303-870-4260 (cell) <br /> —A disabled American veteran owned company— <br /> Authorization Form as required by the Colorado Division of Reclamation Mining and Safety <br /> for Disposal of Hydraulic Directional Drilling Mud, or Hydrovac SIurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> 5280 Stone Company, Longmont, CO 80504 <br /> Name of Generator or Drilling Company, ity, fate,Zi (please print} <br /> 5720 Iris Pky, Longmont amrado <br /> Material's Location/J 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 and/or crops,etc.pursuant to all applicable Federal and State of Colorado/egnlations.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:traclung mud from the pit onto Highway 36 is not permitted by CDOT. <br /> Authorized Generator or Drilling Company Representative: Date: <br /> Brian Tucker <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: /-/9 -Z I <br /> (pieaseprint name} (signature) <br /> n <br /> Z� Date. l8 � <br /> Ricky W. chell, Owner/Operator <br />