2018-03-08_PERMIT FILE - M2018010 (4)

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Form 5510-1 FORM APPROVED (July 2011) UNITED STATES OMB NO,1e 30, 001 DEPARTMENT OF THE INTERIOR Expires:June 30,zo13 BUREAU OF LAND MANAGEMENT Permit Number COC-075940 FREE USE APPLICATION AND PERMIT Expiration Date VEGETATIVE OR MINERAL MATERIAL 10/01/2020 District APPLICATION Royal Gorge Field Office Name of applicant Address(include zip code) FCDOT Fremont County 1170 Red Canyon Road Canon City,CO 81212 Kind of material Sand and Gravel/Roadbase Estimated quantity 150,000 tons Give legal ldiid ucxiiptiun TOWNSHIP RANGE SCION SUBDIVISION 19 S 73 W NE; 19S 73W 19 SE; 1 State,of Colorado County of Fremont Materials are to be used for Construction and maintenance of county roads 1 HEREBY AGRF.F TO COMPLY WITH the special conditions as set forth below l CERTIFY That the.(a)materials to be removed are to be used for the purpose noted above,(b)none of the materials removed are to be sold or bartered;(c)removal of materials can begin only upon receipt of an approved copy of this permit,and,(d)the Bureau of Land Management(BLM)must be notified upon completion of removal 1 CERTIFY That t am a citizen of the United States,and of the age of majority in the State in which l reside I FURTHER CERTIFY That the statements made by me in this application are true,complete,and correct to the best of my knowledge and belief and are made in good faith orb 6 ss (Date) lSignature of Applicant) Title 18 U S C Section 1001,makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,fictitious,or fraudulent statements or repiesentations as to any matter within its junsdiction PERMIT SPECIAL CONDITIONS This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was issued erroneously or the terms or conditions contained herein are not observed It will be subject to the following special conditions See attached conditions. Conservation practices must be carried out as provided by 43 CFR 5511 1-1(b),2-3(c), The permittee must clean up all work areas and must remove or dispose of all refuse and 3-3, resulting from the permittee's operations; Equipment,personal propertv,and improvements must be removed within ninety(90) This permit is issued under die Act of July 31,1947,as amended,and 43 U.S.0 and days after expiration dart 43 CFR 5511 3-5); 1201,and under the free use pi ivdege of the Act of May 14,1896(Alaska only). Any use of the surface of the lands involved in this permit must not interfere with An annual report indicating the amount(cu yds or tons)of material removed must be any mining claim subject to the provisions of Section 4 of the Act of July 23,1955 filed with the District Office on die anniversary date of the permit,or within thirty(30) (30 U S C 613), days after permit expiration(Alaska only) GGG ( atc) (Signature of BI.M (Continued on page 2) APPLICANT F7 FIELD OFFICE