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Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303 - 870 -4260 cell <br />Authorization Form for Clean Inert Material Disposal <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: 7 <br />l2---- <br />/ t � � � /4 1, Q� 6 g. Z <br />Na e of Company, City, State, Zip (please print) <br />Job Site /Location of Material (please print) <br />Name /type of Material (please print) <br />1. Only inorganic inert materials may be dumped at this site. Dumping of any type of <br />contaminated material or soils is not allowed. This includes petroleum products, chemical <br />products, asbestos, and lead -based paints. <br />2. Said Company guarantees that all Clean Inert Material to be disposed of, is both <br />non - hazardous and non - harmful to soil and /or crops, etc. in accordance with all applicable <br />Federal and State of Colorado Regulations. <br />3. Only the transport company authorized below is allowed to dump at this site. <br />4. Material may not be brought into this site on rainy or snowy days, when mud could <br />get tracked or carried onto Highway 36. <br />Autho ed Com y Representative (please print) <br />Autho Company Rep sentative (signature) <br />x c <br />Name of Autho R ed Transport Company (disposing above material) (please print) <br />Aut Tr an Representative Company presentative (please print) <br />Trans o om <br />ized p pany Representative (signature) <br />Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />Rick Mitchell, Owner (signature) <br />3 ©� yto 3� <br />Phone Number <br />Date: Z.l // 7 <br />Date: f/i /' Z - <br />