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Mitchell Sand and Gravel <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 for Clean Inert Material Disposal <br /> as required by the Colorado Division of Reclamation Mining and Safety <br /> Date: /z <br /> f � C6� co r►fiG 3f>3 -38(0 - <br /> Name of Company, City, State, Zip (please print) Phone Number <br /> to to s L_o c. ---r/c,-v <br /> Job Site/Location of Material (please print) <br /> Name/type of Material (please print) <br /> 1. Only inorganic inert materials may be dumped at this site. Dumping of any type of <br /> contaminated material or soils is not allowed. This includes petroleum products, chemical <br /> products, asbestos, and lead-based paints. <br /> 2. Said Company guarantees that all Clean Inert Material to be disposed of, is both <br /> non-hazardous and non-harmful to soil and/or crops,etc.in accordance with all applicable <br /> Federal and State of Colorado Regulations. <br /> 3. Only the transport company authorized below is allowed to dump at this site. <br /> 4. Material may not be brought into this site on rainy or snowy days,when mud could <br /> get tracked or carried onto Highway 36. <br /> Authorized Company Representative (please print) <br /> Date: ✓1 / <br /> Authorized Company Representative (signature) <br /> Name of Authorized Transport Company(disposing above material) (please print) <br /> T il7le <br /> Authorized Transport Company Re resentative (please print) <br /> Date: / <br /> Authorized Transport Company Representative (signature) <br /> Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br /> N <br /> Rick Mitchell, Owner (signature) <br />