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<br /> <br /> <br /> <br /> <br /> <br />1 <br /> <br /> <br /> <br /> ' 1. <br />Form SSIO-I UNITED STATES FOFM APPROVED <br />(ouober 198q ~. DEPARTMENT OF THE INTERIOR OE oNO. I <br />p~ <br />~g~l <br /> I <br />)I <br />.- BUREAU OF LAND h1A NAGEMENT Perme N„meer <br /> FREE USE APPLICATION AND'PERMIT E.pual,on Dme <br /> VEGETATIVE OR MINERAL MATERIAL Disv,a <br /> APPLICATION <br />Name of applicant Address Include eip rode) <br />State De{urtrmst of Rigteays P.O. Bmc 2107 <br />~a~qn~ 0- R7 507-7107 <br />I:md of mater ml I Estimated qua nl rly <br />Sard Stlane I 30,000 Uabic Yards <br />iV6NOHIY kwrvVC SECTION SDDDIV ISION <br />SON. llW 26, NW°1/4 SW 1/4 N+i 1/4 N.M. P.M. <br />State of County of <br />Colorado Montrose <br />Al ateri als are to be used (or <br />Ri~~a for High Sta6ili~atitxL in the bbntrvser Delta aza'as. <br />1 HEREBY AGREE TO COMPLY WITH the special.cond it ions a5 set fo[th below. I CERTIFY Thal the: (a) mat Cria is <br />to 6e removed are to be used (or the purpose noted above; (b) none of the materla is removed are to be sold or bartered; <br />(e)re moval of materials can begin only upon receipt of an approved ropy of this permit; and, (d)Ihe authorized officer <br />is to be notified upon complcl ion of removal. <br />1 CERTIFY Thal f am [went Y-one years of age or older, a citizen of the United Stales, and resident of the State of <br />I FU RTHeR CERrIFY Thal the stale menu made by me in this application are true, complete, and correct [o [he best <br />of my knowledge and belie( and are made in good faith. <br />July 31, 1985 ~ ~- "~ .,~ - <br />(Dare) ' ' (S,gnelure of wppbcanU~ <br />T,IIe IB U.S.C. Sec n 1001, makes ,l s c for •ny per n kno ,ng1Y •nd willfully to moke to nny ^epartmenl a agency of rM1e <br />un i<a suiea .nr n~:.. rcu H.is. or tr.,,a„lem .umm.mepor re P.eunur~om .. m .nr mauv wilmn na i„rumcu m. <br />PERMIT <br />' SPECIAL CONOITION$ <br />This permit is hereby Issued (or the materials applied far but may 6e canceled if it appears that this permit was <br />Issued ertoneously or the terms or conditions contained herein are not obsen'ed. It shall be subject [o the (ol lowing <br />special conditions: <br />1 <br />1 <br /> <br /> <br /> <br />.1 <br /> <br /> <br />Information is collected to comply with Stat~les (l6 U.S.C. 601-606) and agency Regulations (43 CFR 5611.1-1(p). <br />inform anon is used to confirm the residence a( the applicant. <br />P.pplicanl must respond to obtain a permit. <br />Conselvatlon practices must be carried nut as provided <br />by 43 CFR 55] 1.1-1(b), .?-3(c), and .3-3; <br />Equipment, personal properly, and improvements must <br />6e removed wtlhm ninety (90) days after expiration <br />date (i3 CFR 3631.4(c) or 5511.3-5), <br />An}' use of the surface of the lands Involved in this <br />permit shall M such as not to inl cr(cre vnlh any mining <br />claim subject to the proris ions of Section 4 of the Act <br />of July 23, 1955 p0 U.S.C. 613); <br />The permittee shall clean up all work areas and shall <br />remove or dispose a( all refuse resulting from the <br />perm iuee's opemUans, <br />This permit Is Issued under the Acl of July 31, 19x7, as <br />amended, and 43 U.S.C. and 1201, and under the free use <br />pnvllcgc of the Att of M1tay 14, 1899 (Alaska). <br />An annual report indicating the amount (cu. yds. or tans) <br />of material removed .. n..r 6c filed with the Dis- <br />trict Office on the anniversary date of the permit, or <br />within !holy O0) days nlrcr permit expualion. <br />(Dale) _ (S,g_iurc of AmFO_ eJ Of Leer) <br />APPLIC 4Ni <br />