2015-11-18_REVISION - M1987103 - Laserfiche WebLink

Home Browse Search

Sec. 18. Effective date - This contract becomes effective as indicated below. ❑✓ If this contract becomes effective on the date BLM signs the contract, BLM will check this box. El If this contract becomes effective only after certain conditions are met, BLM will check this box, list the conditions below, and indicate the effective date. Sec. 19. Appeal - You may appeal any decision that BLM makes in regard to this contract under Parts 4 and 1840 of Title 43 of the Code of Federal Regulations. The following parties have executed this contract as of: PURCHASER THE UNITED STATES OF AMERICA P/ i 6,zS C•AiS{"'AJCj —' b1/44.By (Individual or Firm Name{ 7? C) L 174 1$ Snipe f C,(* O IL.f. ,2.20 A-wsr ilmar..Er STDorp-r, Mg-ze2 CC gepqz (Address) (BLM) ` `?7a Z42_ 8 (Si j (Phone Number - itflude area code) (Signature) (Signature) If you are a corporation, affix corporate seal here: Ce -40.2 A i ' (Title) Title 18 U.S.0 1001, makes it a crime for any person knowingly or willfully to make to any department or agency of the United States any false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction. subject to a fine of up to SI0,000 and imprisonment up to 5 years NOTICES The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information required by this application. AUTHORITY: 30 U.S.C. 601 et seq.; 43 CFR 3600 PRINCIPAL PURPOSE: BLM uses this information to identify the parties entering into contracts for disposing of mineral materials. ROUTINE USES: BLM will transfer information from the record or the record itself to appropriate Federal, State, local, or foreign agencies, when relevant to criminal, civil, or regulatory investigations or prosecutions. EFFECT OF NOT PROVIDING INFORMATION: If you do not provide this information to BLM, we will not be able to process your application for a contract. The Paperwork Reduction Act of 1995 requires us to inform you that: The BLM is collecting this information to process your application and effect a binding contract. The BLM will use this information to identify and communicate with applicants. You must respond to this request to get a benefit. Thc BLM would like you to know that you are not required to respond to, this or any other Federal agency -sponsored information collection which does not have a currently valid OMB control number. BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0103), Bureau Information Collection Clearance Officer (WO -630). 1849 C Street, N.W., Mail Stop 401 LS, Washington. D.C. 20240. (Form 3600-9, page 3)