Laserfiche WebLink
i7,' ,4, C111" <br /> p,q '7/3120 <br /> Mitchell Sand and Gravel f <br /> 48580 Hwy 36-P.O. Box 10, Bennett, CO 80102 Date: ` l <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 /> air G <br /> Name of Generator or Drilling Company, City, State,Zip (please print) <br /> wtz' tiitX�7�E <br /> Material's Location/Job Site (please print) <br /> _Dj _,iU.,jl� <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 Regulations.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: 1,21101 <br /> (please print name) (signature) <br /> A-4,v(1DP_0 i SDvf�b� <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above material: Date: <br /> S� r� IAA <br /> (please print name) (signature) <br /> Date: <br /> Ricky W. NRfc%ell, Owner/Operator <br /> RECEIVED DEC 1 12019 <br />