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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 as required by the Colorado Division of Reclamation <br /> Mining and Safety for Disposal of Ground Water and/or Hydrovac Slurry Water <br /> Date: <br /> Name of Generator, City, State,Zip ( ease print) <br /> Generator's Location/Job Site (please print) <br /> Name/type of Materia luid Disposing (please print) <br /> Generator 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 <br /> Colorado Regulations,including Rule 907 of the Colorado Oil and Gas Conservation <br /> Commission. if adverse weather(rain,snow),please contact me first: tracking mud <br /> from the pit onto Highway 36 is not permitted by CDOT. <br /> Authorized Generator Company Representative (please print) <br /> Date: t <br /> Xu thorized Generator Company Representative signature <br /> A+e.2 SP.e2j , LIB <br /> Name of Transport Company disposing of above material (please print) <br /> �okN 'Ll <br /> Transport Company Rep sentative (please print) <br /> Date: (�I a 9 <br /> Transport Company Representative signature <br /> Fluid DisposaUDestination:Mitchell Sand and Gravel Pits Bennett.CO 80102 <br /> i <br /> Rick Mitch 11,Owner <br />