PERMFILE58324

• Permit No: M1986037
• IBM Index Class Name: Permit File
• Doc Date: 4/2/1986
• From: BLM
• To: MLRD
• Media Type: D
• Archive: No

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Form 5510-1 UNITED STATES
(October 19817 DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FREE USE APPLICATION AND PERMIT
V EGETA TIME OR MINERAL MATERIAL

FORM APPROVED
OMB NO. 1001-0001
E+Direa: 10/P /94
I`vrma Number
-~
C 0 -O-jO - M Fai S ~yy~~yQ~ _
Eaptrm~p.m~l (990 0 {~~~~~ °~
Name of applicant Address I iu lode zip rode)
State IklxirGlent of Highways P.O. Box 2107
Kind of materiel Estimate
Sall Stone 30
Give legal land description
TOVNSHIP RANGE SECTION ~ SUBDIVISION
SON. 11W 26, NW 1/4 SW 1/4 NW 1/4 N.M. P.M
Slate of County of
lblorado MontYOSe
Materiels e+e Lo be used for
Rip-Fop for Highway Sta_biliution in the hbnUtise, Delta areas. _
1 HEREBY AGREE TO COMPLY WITH the special conditions as se[ forth below 1 CERTIFY That Ihe: (e) materials
to be removed ere [o be used for [he purpose noted above; (h) none of the materials removed ere to be sold or bartered;
(c)removal of materials can begin only upon receipt of en approved copy of this permit: and, (d) the authorized officer
is to be notified upon completion of removal.
1 CERTIFY Thet I em twenty-one years oL ago ar older, a citizen of the United Slates, end resident of the Slate of
I FURTHER CERTIFY Thet the statements made by me in this application ere true, complete. and correct to the hest
of my knowledge and belief end are made in good faith.
July 31, 1985 ~r-l4 // ~i /,jrii
(Dam) (signature of ADPImanU
Title IB U.S.C. Secllon IDDI, makes 11 • crime for any perean knowingly and willfully la make to •nY deDertmem o agency o! IM1e
Unlled Srero any lobe, IIcUr,oua, or (reudolem •Ptemenu o regaentnlona as to any meuer wuhm Ila lurladiuion.
PERMIT
SPECIAL CONDITIONS
This permit is hereby issued for the materiels applied for buC may be canceled i( it oppears that thrs permit was
Lssued enoneously or the terms or conditions contained herein er¢ not observed. 11 shall be subject to the following
special conditions:

Information is collected to comply with Statutes (16 U.S.C. 609-606) end agency Regulations (43 CFR 5511.1-I(f)),
rnformation is used to confirm the residence of the applicant. _
Applicant must respond to obtain a permit.
Conservation prectices must be carried out as provided
by 43 CFR 5511.1-1(b), .2-3(c), end 3-3;
Equipment, personal property, end improvements must
be removed within ninety (90) days after expiration
dale (43 CFR 3621.4(c) or 5511.3-5);
Any use of the surface of the lands invoh•ed in this
The perm ittee shall clean up all work areas and shall
mmove or dispose of ell infuse rcsull ing from the
perm iltee's operations;
This patina is issued under the Act of July ]], 1947, as
amended, end 43 U.S.C. and 1201, and under the free use
privilege a( the Att of May 14, 1898 (Alaska).
permit shell tr Such as not to interfere with any mining I An annual report indicating the nmounl (cu. yds. or tons)
claim subject to the provisions of Section 4 of the Acl of material removed m,ur be filed with the Dis-
of July 23, 1955 (30 U.S.C. 613); Irict Office on the anniversary date o! the permit, or
with' lhury t )0) days a/err permit expiration.
ion,/ - ~ ~ _ ~ ~~ -
/ (Dare) (&gnalme o1 A oriaed Olliceq
APR 2 1986
MINED LAND
Yards RECLAMATION DIVI910~
DISIRICi OFFICE