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Form 5510-1 FORM APPROVED <br /> (July 1993) UNITED STATES OMB NO.1f1(N-0001 <br /> DEPARTMENT OF THE INTERIOR Expires: May 31.1996 <br /> BUREAU OF LAND MANAGEMENT Permit Number <br /> FREE USE APPLICATION AND PERMIT Expiration Date <br /> VEGETATIVE OR MINERAL MATERIAL <br /> APPLICATION District <br /> Name of applicant Address fmclu&zip Lode) P(L 8CX Xot 570 <br /> Kind of material Estimated quantity <br /> Y��'L1 C10O 3 <br /> Give legal land description <br /> TOWNSHIP RANGE SECTION SUBDIVISION <br /> 7-2..5 <br /> State of I 'County k16 <br /> Materials are to be used for <br /> 1 HEREBY AGREE TO COMPLY WITH the special conditions u set forth below.1 CERTIFY That the:(a)materials to be removed arc to be used for the purpose noted <br /> above;(b)none of the materials removed are to be sold or bartered;(c)removal of materials can begin only upon receipt of an approved copy of this permit;and,(d)the <br /> authorjnd oficer is to be notified upon completion of removal. <br /> I CERTIFY That 1 am a citizen of the United States,and of the age of majority in the State in which Inside. <br /> 1 FURTHER CERTIFY That the statements made by me in this application are true,complete,and correct to the best of my knowledge and belief and are made in good <br /> faith. <br /> (Date) Z (Signature of Applicant) <br /> Title IS U.S.C.Suasion 1001.mskn itaarimefor mypermn knowinglyand willfully,.msket.any ep of oragencyof the United Slatesaayfalse,fictitious,orfnudulent statements or <br /> repre.+mtstiuns as to say matter viLhin 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 issued erroneously or the terms or conditions contained <br /> herein are not observed.It shall be subject to the following special conditions: <br /> 4Ov017-1al1 /1rX1fe1'6:2> <br /> Conservation practices outu be carried out at provided by43 CFR 5511.1-1(b),.2-3(c), The permittee shall clean up all work areas and shall remove or dispose of all refuse <br /> and.3-3; resulting from the permittee's operatiom; <br /> Equipment.personal property,and improvements must be removed within ninety(90) This permit is issued under the Act of July 31.1947,as amended,and 43 U.S.C.and <br /> days after expiration date 43 CFR 5511.3-5); 1201,and under the free sex privilege of the Act of May 14,1898(Alaska only). <br /> Any use of the surface of the lands involved in this permit shall be such as not to An annual report indicating the amount(cu.yds.or tom)of material removed murt be <br /> interfere with any miningclaim subject to the provisions of Section 4 of the Act of July filed with the District Office on the anniversary date of the permit,or within thirty(30) <br /> 23.1955(30 U.S.C.613); days after permit expiration(Alaska only). <br /> JU <br /> � f (Date)' �V(Sigaat of'Authorized Officer) <br /> APPLICANT <br />