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Mkcbell Sand and Grave <br /> 49M Hwy 36-P.O.Box 10, Bennett,CO 80102 Date: k 1 s <br /> 303-8704260(cell) <br /> A disabled American veteran owned company <br /> Authorization Form as required by the Colorado Division of Reclamation Mining and Safety <br /> for Diapocal of Hydrsulie Directional Drilling Mud,or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> 1�'— <br /> Name of Genneaator or Drilling Company,City,Stat,,Zip (please print) <br /> Material's Location/Job Site (please print) <br /> l r <br /> Type of Material Disposing (please print) <br /> Generator or Drilling Company guarantees that aH material to be disposed of is both neon-hazards am <br /> non-harmfal to soil and/or crops,ete.puraant to all applicable Federal and State of Colorado Regulations.AL <br /> material is"inert material"as defined a"non-water-soluble and non-pateescible solids together with sneb minor <br /> amounts and types of other materials,unless sock materials are acid or tour prodacin&as will not dpificantp., <br /> sect the inert nature of such solids. The term iaclades.but is not limited to,earth,sand,gravel,rock,concrete <br /> which has been in a hardened state for at least sho days,masonry,asphalt paving fragments,and other inert solids". <br /> 'n adverse weather,contact me first:h aching mud from the pit onto MOWay 36 is not permitted by CDOT. <br /> authorized Generator or Drilling Company Representative_ Date. <br /> (please print name) (signature; <br /> came of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above material: Date: I <br /> (please print name) (signatuue) <br /> Date: �( ! <br /> Ricdry W.MtcheI4 OwnerA)pera:v <br />