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Authorization Form for Clean Inert Material Disposal <br />as required by the Colorado Division of Reclamation Mining and Safety <br />Date: t - i i \ 2 <br />Name of Company, City, State, Zip (please print) <br />Job Site /Location of Clean Inert Material (please print) <br />ii■Oc Z.-L.-CAIN .6 <br />Said Company guarantees that all Clean Inert Material to be disposed of, is both non- <br />hazardous and non - harmful to soil and /or crops, etc., in accordance with all applicable <br />Federal and State of Colorado Regulations. <br />Authorized Company Representative (please print) <br />Authorized Company Representative signature <br />1 <br />2 <br />Mitchell Sand and Gravel <br />48580 Hwy 36 - P.O. Box 10, Bennett, CO 80102 <br />303 - 644 -4102 303 - 870 -4260 cell <br />Name /type of Material (please print) <br />Name of Transport Company disposing of above material (please print) <br />- 7 Li <br />(r) ONE 175 <br />Transport Company Representative (please print) <br />Transport Company Representative signature <br />Rick Mitchell, Owner <br />Date: f /24/ 11.. <br />Date: 31 /12 <br />Clean Inert Material Disposal/Destination: Mitchell Sand and Gravel Pits, Bennett, CO 80102 <br />