Laserfiche WebLink
M � <br /> Sec.18.Efferllve dale-This contract becomes effective as indicated below. <br /> 0 If this contract becomes effective on the date BLM signs the contract,BLNI will check this box. <br /> ❑ If this contract becomes effective only after certain conditions arc met.BLNI will check this box,list the conditions below,and indicate the <br /> effective date. <br /> Sec.19.Appeal-You may appeal any decision that BLM makes in regard to this contract under Parts 4 and 1840 of fide 43 of the Code of Federal <br /> Regulations. <br /> The following panics have executed this contract as of: <br /> PURCHASER THE UNITED STATES OF AMERICA <br /> By David Lazorchak <br /> (Individual or Firm Name) (Print Name of BLM Official) <br /> DAVID LAZORCHAK - ----- ------ <br /> (Address) (Signature of BLM Official) <br /> Geolo9m <br /> (Phone Number-include area code) (Title) <br /> 08119/2015 <br /> (Signature) (Date) <br /> (Signature) <br /> If you are a corporation,affix corporate seal here: <br /> Title 18 U.S.C.1001,makes it a crime for any person knowino or willfully to make to any department or agency of the United States any false fictitious or fraudulent <br /> slatcnrcrgs or mpreswitodom as to any maticr within its jurisdiction,subject to a f inc ofup to$10,000 and imprisonment up to 5 years. <br /> NOTICES <br /> 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 <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 from 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 1 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 of this 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 /> rt� <br />