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Mitchell Sand and Gravel <br /> 4M Hwy 36-P.O.Box 10, Bennett,CO Sol02 per: 4 <br /> 303-870-4260(cdl) <br /> A disabled American veteran owned company a <br /> Authorization Form as required by the Colorado Division ofReclamation Mining and Sa"- <br /> for Dirpoesl of Hydranlie DiPOMOnal Drilling Mod,or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> Name of Generator or DnI4 Co any,City,State,Zip (please print) <br /> CA- <br /> Material's Location4bb Site (please print) <br /> Type of Material Disposing (please print) <br /> Cencratur or Dn7ling Company guarantees that A material to be disposed of is both non4umardous and <br /> non-harmN to soil and/or crops,etm pursuant to AU applicable Federal and State of Colorado Regulations.AU <br /> material is"inert material"as defined as"nos-water-soluble and non-patreaclble solids tgptherwith web minor <br /> ones:and types of other materials.Unless each materials are add or toxic producing,as will not significandy <br /> affect the inert nature of such solids. 17he term includes,but is not limited to,earth,sand,gravel,rock,eoncreft <br /> which has been in a hardened state for at least dsty days,masonry,asphalt paving fragment,and other inert solids". <br /> In adverse weather,contact me first:Umddng mad from the pit onto Highway 36 is not permined by CDOT. <br /> Authorized Generator or Dnllmg Company Representative: late: <br /> r <br /> (please prim name) (sigmature) <br /> Name of Transport Company disposing of above material (please prim namel <br /> Name of Transport Company Representative disposing of above material: Date: <br /> 6015 <br /> (please print name) (signatrrte) <br /> r ism, - C ,Zl <br /> Ricky WAfitchell,Owner/Oper= <br />