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Mitchell Sand and Gravel <br /> 48S80 Hwy 36-P.O.Box 10, Bennett,CO 80102 Date: <br /> 303-87"260(cell) <br /> A disabled American veteran owned company <br /> Authorization Form as required by the Colorado Division ofReclamation Mining and Safety <br /> for Disposal of Hydraulie Directional Drilling Mud,or Hydrovac Slurry Water, <br /> or Water Based Bentouitic Drilling Fluids from Water Well Drilling. <br /> � F,1r_raAr, <br /> Name of Generator or Drilling Company,City,State,Zip (please print) <br /> Material's Location/Job Site (please priest) <br /> Type of Material Disposing (please print) <br /> Generator or Drilling Company guarantees that al!material to be disposed of is both non-hazardow and <br /> non4wnifal to soil and/or crops,etc,porinont to all applicable Federal and State of Colorado Begat ltiOUL All <br /> material is"inert material"as defined as"non-water-soluble and non- au escibie solids together with such minor <br /> 2mouers and types of other materials,unless such materials an add or toxic producing,as WM not sigffkantly <br /> affect the inert naty, of such solids. The term indada,but is not limited to,earth,sand,gravel,rock,conger- <br /> which has been in a hardened state for at least sixty days,masonry,asphalt paving fragment*and other inert solids'. <br /> in adverse weather,contact me firm:tracbng mad from the pit onto Highway 36 is not permitted by CDO!x <br /> Authorized Generator or Drilling Company Representative: Date: <br /> (please print name) (4nature) <br /> Y <br /> Name of Transport Cornpany disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above material: Date: k <br /> r (please print name) (mgnaftn) <br /> r <br /> irate: / /14 <br /> Ricky .Mitchell,Owner/Operator <br />