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Mitchell Sand and Grave( <br /> 48580 Hwy 36-P.O.Box 10, Bennett,CO 80102 Date: k <br /> 303-870-4260(cell) <br /> A disabled American veteran ownea company <br /> Authorization Form as required by the Colorado Division of Reclamation Mining and Safety <br /> for Diepocal of Hydraulie Directional Drilling Mud,or Hydrovac Slurry W arer, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> Name of Generator or Drrl 4 Company,City,State,Zip (please prim) <br /> Material's Locatioklob Site (pl print) <br /> Type of Material Disposing (please print) <br /> Generator or Drilling Company Vmw tea that an material to be disposed of is both non-hazardaus and <br /> noa-harmN to soil and/or crops,etc.porn wit to all applicable Federal and State of Colorado Regulations,All <br /> material is"inert material"as defined as"non-water-soluble and non-putrescibk solids togetberwiW with minor <br /> smoaats and types of other materials,unless such materials are add or toric producing,as will not sigpgk&Dtly <br /> afred the inert nature of such solids. The term indades,but is not limited to,earth,sand,gravel,rock,concrete <br /> which has been in a hardened state for at last shy days,masonry,asphalt paving fragments,and other inert solids". <br /> in adverse weather,contact me first:traddng mud from the pit onto Highway 36 is not permitted by CDOT, <br /> Authorized Generator or Drilling Company Representative: Date: <br /> IL <br /> (please print name) (signature) <br /> t --- <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Repmsentative disposing of above material: Date: <br /> (pkase print name) (signature) <br /> Data <br /> l <br /> Ricky W. ell,Owner/Oaerator <br />