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<br />Form 5510-1 UNITED STATES FORM APPROVED <br />(January 1979) DEPARTMENT OF THE INTERIOR OMB NO. 42-80875 <br /> BUREAU OF LAND MANAGEMENT Permit Number <br /> FREE USE APPLICATION AND PERMIT Exp'vation Date <br /> VEGETATIVE OR MINERAL MATERIAL District <br /> APPLICATION <br />Name of applicant Address (include zip code) <br /> <br />Kind of material <br />nnr Estimated quantity <br />_ - <br />Give legal land de scription <br />TOWNSHIP RANGE SECTION SUBDIVISION <br /> <br />State of County of <br />~... ,~effaL <br />Materials are to be used for <br />. - ,,~~ <br />I HEREBY AGREE TO COMPLY WITH the Special Conditions as set forth below. I CERTIFY That the: (a) materials <br />to be removed are to be used far the purpose noted above; (b) none of the materials removed are to be sold or bartered; <br />(c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d)the authorized officer <br />is to be notified upon completion of removal. <br />1 CERTIFY That I am twenty-one years of age or older, a citizen of the United States, and resident of the State of <br />I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best <br />of my knowledge and belief and are made in good faith. <br /> <br /> <br />(Date) <br />Tile 18 U.S.C. Section 7001, makes it a crime for any person knowingly and willfully to make (o any department or agency o[ [he <br />United Steles any Calse, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction. <br />PERMIT <br />SPECIAL CONDITIONS ~ <br />This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was -- <br />issued erroneously or the terms or conditions contained herein ere not observed. It shall be subject to the following <br />special conditions: <br /> <br />Conservation practices must be carried out as provided <br />by 43 CFR 5511.1-1(b), .2-3(c), and .3-3; <br />Equipment, personal property, and improvements must <br />be removed within ninety (90) days after expiration <br />~ date (43 CFR 3621.4(c) or 5511.3-5); <br />Any use of the surface of the lands involved in this <br />permit shall be such as not 20 interfere with any mining <br />claim subject to the provisions of Section 4 of the Act <br />of July 23, 1955 (30 U.S.C. 613); <br />AUG 2 2 1980 <br />The permittee shall clean up all work areas and shall <br />remove or dispose of all refuse resulting from the <br />permittee's operations; <br />This permit is issued under the pct of July 31, 1947, as <br />amended, and 43 U.$.C, and 1201, and under the free use <br />privilege of the Act of May 14, 1898 (Alaska). <br />An annual report indicating the amount (cu. yds. or tons) <br />of material removed must be filed with the Dis- <br />trict Office on the anniversary date of the permit, or <br />withyt thirty (90) days a/tar permit expiration. <br />Authorized Officer) <br />/ _ <br />APPLICANT <br />