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Sec.18.Effective date-This contract becomes effective as indicated below. <br /> 0 if this contract becomes effective on the date BLM signs the contract,BLM will check this box. <br /> ❑ If this contract becomes effective only after certain conditions are met,BLM will check this box,list the conditions below,and indicate the <br /> effective date. <br /> See.19.Appeal-You may appeal any decision that BLM makes in regard to this conuact under Parts 4 and 1840 of Title 43 of the Code of Federal <br /> Regulations. <br /> The following parties have executed this contract as of <br /> PURCHASER rTHE UNITED STA OF AME A <br /> [�.By David rchal <br /> !j ( or W NWelBLM OM ) <br /> i <br /> �1 t111 �. <br /> (Address) / i f Official) <br /> 2 `Z Geologist <br /> ( Number——include area code) (Title) <br /> / Sigma) (Doe) <br /> (Sipes) <br /> Ifyou are a corporation,affix corporate seal here: <br /> TWe 18 U.S.C.1001,makes it a crime lbr any person or wtUW*to mace to any depan»tatt or agency oftbe United States any false.fsCWM or fiaudula% <br /> stop meats or represandom BID any wmw within its�juM,s*ject to a fine of up to 51%000 and imprisanratt up tat S yeas. <br /> NOTICES <br /> The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)provide that you be famished the following information in connection with information <br /> required by this application. <br /> AUTHORITY:30 U.S.C.601 et seq.;43 CFR Group 3600 <br /> PRINCIPAL PURPOSE:BLM uses this information to identify the parties entering into contracts for disposing of mineral materials. <br /> ROUTINE USES:BLM will transfer information fiom the record or the record itself to appropriate Federal,State,local,or foreign agencies,when <br /> relevant to criminal,civil.or regulatory investigations or prosecutions. <br /> EFFECT OF NOT PROVIDING INFORMATION:If you do not provide this information to BLM,we will not be able to process your application for <br /> a contract <br /> The Paperwork Reduction Act requires us to inform you that: <br /> The BLM is collecting this information to process your application and effect a binding contract <br /> The BLM will use this information to identify and communicate with applicants. <br /> You must respond to this request to get a benefit <br /> You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a valid OMB control number. <br /> BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about I hour per response.including the time for <br /> reviewing instructions,gathering and maintaining data,and completing and reviewing the form.You may submit comments regarding the burden estimate <br /> or any other aspect ofthis form to: U.S.Department of the Interior,Bureau of Land Management(1004-0103).Bureau Information Collection Clearance <br /> Officer(WO-630),1849 C Street,N.W.,Room 2134LM,Washington,D.C.20240. <br /> (Form 3600-9,page 3) <br /> � J <br />