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M tchell Sand and Gravel <br /> 48580 Hwy 36-P.O.Box 10, Bennett,CO 80102 Date: , <br /> 303-870-4260(cell) <br /> A disabled American veteran owned company <br /> Authorization Dorm as required by the Colorado Division otRodamation Mining and Safety <br /> for Disposal of Hydraulic Dir#Monal Drilling Mnd,or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> Name of Generator or Drilling Company,City,Static,Z/i�p* (please print) <br /> Matenal's Location/Job Site (please print) <br /> Type of Material Disposing (please print) <br /> Generator or Drilling Company gu uwitees that al material to be disoased od is both non-uazaraaaa an. <br /> non haradal to soil and/or crops,ft pursuant to all applicable Federal and State ad Colorado Regnlatkm A: <br /> material is"inert material"as defined as"non-water-soluble and non-putr+escibie solids topether with sacs mmr <br /> amounts and types of other materials,unless saeh materials are acid or tnic producing,as will not sigailirant.; <br /> Whet the inert nature of such solids. I%e term includes,but is not limited to,earth,sand,gravel,rock,concrete <br /> ;.inch has been in a hardened state for at last sixty days,masonry,asphalt paving fragments,and other inert solids". <br /> adverse weather,contad me first:tracbng mod from the pit onto Noway 36 is not permitted by CDOT. <br /> Authorized Generator or Drilling Company Representative: Bate: k <br /> kaA <br /> (please print name) (S* ' <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above matcrial: Date: <br /> (please print name) (si8nattm) � <br /> WeLOf Date: <br /> Ricky W.Mb&14 Owner/Operator <br />