2013-05-20_REVISION - M1984094 ‎(7)‎

• Permit No: M1984094
• IBM Index Class Name: Revision
• Doc Date: 5/20/2013
• Doc Name: Adequacy Response
• From: Sanborn Sand and Gravel
• To: DRMS
• Type & Sequence: AM2
• Media Type: D
• Archive: No

Affidavit For Import of Materials into Gloria Z Pit
Date or Time Period of Import:
Description of Import Material:
Entity Providing Material to Pit (not the trucking Company):
I hereby certify that the material described above and brought to the Gloria Z Mine site is inert,
which means it is free from any chemicals, toxic substances, acid forming material, or any other
material which would violate the material waste disposal laws of the State of Colorado.
Signature
Written Name of Signer
Signer's Position in Company Company
Date:
Gloria Z Mine 2013 Amendment 16