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Mitchell Sand and Gravel <br /> 48580 Hwy 36-P.O.Box 10, Bennett,CO 80102 Date: 9.7 r2Y <br /> 303-870-4260(cell) <br /> A disabled American veteran owned company <br /> Authorization Form as required by the Colorado Division of Reclamation Mining and Safety <br /> for Disposal of Hydraulic Directional Drilling Mud,or Hydrovac Slurry Water, <br /> or Water Based Bentonitic Drilling Fluids from Water Well Drilling. <br /> JT h >'►'t ��aw, 4 <br /> Name of Generator or Drilling Company, City, State,Zip (please print) <br /> �.4D6 < ��<<o /@r 17� Sow <br /> Material's Location/Job Site (please print) <br /> !T I(Ata;f-4 &,.- <br /> Type of Material Disposing (please print) <br /> Generator or Drilling 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 defined as"non-water-soluble and non-putrescible solids together with such minor <br /> amounts and types of other materials,unless such materials are acid or toxic 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 for 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: <br /> Date: 4 - <br /> (please print name) (signature) <br /> t �i.�ar �A�� �C <br /> Name of Transport Company disposing of above material (please print name) <br /> Name of Transport Company Representative disposing of above material: Date: g'2-Z/ <br /> 6011t! <br /> please print name) (signature) -r <br /> � Date: ?A1124 <br /> Ricky . tchell, Owner/Operator <br />