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See.18.Effective dale-This contract becomes effective as indicated below. <br /> Q If this contract becomes effective on the dale BLhi 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 /> 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 tlx:Code of Federal <br /> Regulations. <br /> The following parties have executed this contract as of: <br /> PURCHASER TI IE UNITED STATES OF AMERICA <br /> By David Lazorchak <br /> (Individual or Firm Name) (Print Name of BLM Official) <br /> (Address) (Signature of BLM Official) <br /> Geologist <br /> (Phone Number—include area code) (Title) <br /> 11107/2014 <br /> (Signature) (Date) <br /> (Signature) <br /> If you are a corporation,affix corporate seal here: <br /> Tide 19 US.C.1001,makes it a crime for any person k nowirrgly or willfully to mafu:lo arty department or agency of the United States any false,ficlitkus or fraudu[em <br /> slatments or representations as w arty matter within its jurisdiction,subject to a frne of up to S 10,000 and irrrlrlsonment up to 5 years. <br /> NOTICES <br /> The Privacy Act of 1974 and the regulation in 43 CFR 2A8(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 INFORf11ATION:Ifyou do not provide this information to BLM,%v 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 of this form to: U.S.Department of the Interior,Bureau of Land Management(1004-0I03} Buroau 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 /> 0.-2,6 � <br />