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Y ~i Form 5510.1 ~ • FORM APPROVED (May 1985) UNITED STATES OMB NO. 1004-0001 DEPARTMENT OF THE INTERIOR Expires: Ottobcr 31, 1987 BUREAU OF LAND MANAGEMENT Permit Number CO-050-RG-FU-90-13 FREE USE APPLICATION AND PERMIT Expiration Date VEGETATIVE OR MINERAL MATERIAL Oct. 1 1993 District APPLICATION CO-050 Name of applicant ress rn !u i r '~i~emdnf ~etitQnf~)Courthouse Fremont Count Canon City, CO 81212 Kind of material Estimated quantity Gravel Give Icgal land description TOWNSHIP RANGE SECTION SUBDIVISION 49 N. 11 E. 2 NE}NE} State of County of Colorado Fremont Materials are to be used for Countv Road Maintenance I HEREBY AGREE TO COMPLY WITH the special conditions az scl forth below. 1 CERTIFY That lhc: (a) matcrials to be rcmoved ere to be used for the purpose noted above; (b) none of the materials rcmoved are to be sold or bartered; (c) removal of materials can begin only upon rettipt of an approved copy of this permit; and, (d) the authoriud ofittr is to Iz notified upon completion of removal. I CERTIFY That I am :t citizen of the United Stales, and of the age of majority in the State in which 1 reside. I FURTHER CERTIFY'fhal the statements made by me in this application art true, Complete, and correct to the best o(my knowledge and belief and arc made in good faith. (Date) (Signature of Applicant) Tide I a U.S.C. $ecuon IIX~ I, maker it s crime (or any person knowingly and willfully to make to any depsrtment or agency of the United States aoy falfe, fic[itiaaq or fraudulent 1latements or rtprcseNations at to any matter within its jurisdiction. PERMIT SPECIAL CONDITIONS This pcrmit is hereby issued for the matcrials applied for but may be canceled if it appears that this permit was issued erroneously or the toms or conditions contained herein art not observed. It shall be subject to the following special conditions: Soil Conservation Service Reclamation Plan or other approved plan will be utilized. Trees along the southern boundary of the permit area will be preserved. Highwalls are not authorized. Final contours will be maintained during the mine life Information is collected to comply with Statutes (16 U.S.C. (A4fi06 and agency Regulations (43 CFR 5511.1-I(f)). Information is used to confirm the residrntt of the applicant. Applicant must respond to obtain a permit Conservation practices inusr be carried out az provided by 43 CFR 551 I.I-I(b), .2-J(c), and .3-3; , Equipment, personal property, and improvements mart be rcmoved within ninety (90) days after expiration date 47 CFR 5511.3-5); Any use of the surface o(the lands involved in this permit shall be such as not to intcrfctt with any mining claim subject to the provisions of Section 4 o(thc Am of July 23, 1955 (30 U.S.C. 61 J); 3 The permitttt shall clean up all work areaz and shall remove or dispose of ell refuse resulting from the permitttt's operations; This permit is issued under the Act of July 31, 1947, es emended, and 43 U.S.C. and 1201, and under the free use privilege of the Act o(May 14, 1698 (Alaska). An annual report indicating the amount (cu. yds. or tons) of material rcmoved must be filed with the District Offze on the anniversary date of the pcrmit, or within rhnrr (30) days after permit cxpirauon. (Signature of Authorized Officer) APPLICANT