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Sec.18.Effeclh-e dare-This contract becomes effective as indicated below. <br /> 0 if this contract becomes effective on the date BLM signs the contract,BLDI 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 <br /> Indicate the 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 the Code of <br /> Federal Regulations. <br /> The following parties have executed this contract as of- <br /> PURCHASER THE UNITED STATES OF AMERICA <br /> 1 �_ —__ By— <br /> (individual or Firm Namef w_ <br /> _ 71 50"74- 15r44- Sim f lr Ah <br /> Address (BLM) <br /> q7a ZIV- s I'SI AAAIA.�.1 <br /> (Phone Number-10c ude area code) (Title) <br /> ✓ (Signature) -r to <br /> (Signature) <br /> If you are a corporation,affix corporate seal here: <br /> 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 <br /> statements or reptesentations as to any miter within its iurisdiction,subiect to a fine of up to sio 000 and imprisonment up to 3 Years <br /> NOTICES <br /> The Privacy Act of 1974 and the regulation in 43 CFR 2AS(d)provide that you be furnished the following information in connection w ith information <br /> required by this application. <br /> AUTHORITY:30 U.S.C.601 ct seq.;43 CFR 3600 <br /> PRINCIPAL PURPOSE:BLM uses this information to identify the parties entering into contracts for disposing of mineral maleriais <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:1f you do not provide this information to BLM,we will not be able to process your application for a <br /> contract. <br /> The Paperwork Reduction Act of 1995 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 /> The 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 <br /> not have a currently valid OMB control number. <br /> BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average about 30 minutes per response,including the <br /> time for reviewing instructions,gathering and maintaining data,and completing and reviewing the form.Direct comments regarding the burden <br /> estimate or any other aspect of this form to U.S.Department of the Interior,Bureau of Land Management(1004-0103),Bureau Information <br /> Collection Clearance Officer(WO-630).1849 C Street.N.W..Mail Stop 401 LS,Washington.D.C.20240. <br /> (Form 3600.9.page 3) <br />