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Mitchell Sand and Gravel <br /> 48580 Hwy 36-P_U_Box 10, Bennett; CO 80102 Date: 1,;?11,912 <br /> 303-870-4260(cell) <br /> A disabled American veteran owned company <br /> Authorization Farm as required by the Colorado Division dflt"hunation Alining and Safety <br /> for Disposal of Hydraulic Directional Drilling Mad,or Hydrevac Slurry Water, <br /> or Water Based Bentorutic Drilling Fluids from Water Well Drilling. <br /> Name of Generator or Drilling Company,City,State,Zip (please print) <br /> Tob It 05,�o q Tog* b".�o 9 OE VaE q WA-rF'Q <br /> Material's Location/Job Site (please print) <br /> _AiLr wwi- , L � AU. M sS - Coo 21 i i <br /> Type of Material Disposing (please print) <br /> Generator or Doling Company 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 Colorado Regulations.All <br /> material is"inert material" as det fined as"non-water-soluble and non puhvwible solids together with such minor <br /> amounts and types of other materials,unless such materials are acid or tw is producing,as will not significantly <br /> affect the inert nature of such solids. The term includes,but is not limited to,earth,sand,gravel,rock,concrete <br /> which has been in a hardened state fdr at least sixty days,masonry,asphalt paving fragments,and other inert solids". <br /> In adverse weather,contact me first;tracking mud from the pit onto Highway 36 is not permitted by CDOT. <br /> Authorized Generator or Drilling Company Representative: Date: 1,2 16o ww <br /> 5Z 14 <br /> (please print name) (signatare) <br /> �u�� <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Company Rep-resen-,alive disposing of above ratzria!: <br /> ►�, PAL( <br /> (please print name) (signature) <br /> 4,� i <br /> a Date: 1-2 10 v?1 <br /> Ricky W ell,Owner/Operator <br />