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Mitchell Sand and Gravy <br /> 4=0 Hwy 36-P.O.Box 10, Bennett,CO, 90102 Daze: -,x <br /> .V3470-4260(cell) <br /> A disabled American veteran ownea company <br /> Authorization Form as required by the Colorado Division ofliM mation Mining and Safety <br /> for Dicpocal of Hydranlie Dhwfional Drilling Mad,or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> Name of Generator or Dn1Lng Company,City,State,Zip (please print) <br /> Material's Location/ob Site (please print) <br /> Type of Material Disposing (please print) <br /> ;ene awr or DnVwg Company V arantm that an material to be disposed of is both non-hazardoas and <br /> aon-harmfal to OR and/or crone,ft pursuant to aU applicable Federal and State of Colorado Begaladons.All <br /> material is"inert material"as defined as"non-water-soluble and non-patrescible solids together with such minor <br /> -:mounts sad types of other materials,unless sneh materials are and or tmdc producin&as win not s4wirwAntly <br /> affect the inert nAu re of such solids. Ile term Wftdes,but is not limited to,earth,sand,gravel,rude concret <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;trarlong Band from the pit onto Ewa'36 is not permitecd by CDO, <br /> Authorized Generator or Drilling Company Representative: Bate: �L5 <br /> (please print name) (signature) <br /> 1.�.,1 <br /> Name of Transport Company disposing of above material (please Drint name; <br /> Name of Transport Company Represematiive disposing of above material: Date: <br /> (please print name) (signature) <br /> Ricky W.Wtchell,Owner/Operator <br />