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Form 5510.1 FARM APPROVID <br />puffy 1993) UNITED STATES Fp~pM{~ °~~y 3001- ~1 <br />DEPARTMENT OF THE INTERIOR permit Number <br />BUREAU OF LAND MANAGEMENT <br />C' - 6Syo5 <br />FREE USE APPLICATION AND PERMIT Expiration Dale <br />VEGETATIVE OR MINERAL MATERIAL 2 - <br />District <br />APPLICATION G l DOS <br />Name of applicant Address (include zip code) <br />~ ,~ ti ~. 6,c ~ 5 ~ co suers h,~,,,, ~~ ~ ti~~L . e <br />Kind of material 5 N ~ Estimated quantity <br />TOWNSHIP RANGE SErT10N SUBDIVISION <br />2 ~tJ /d ! w ! z aES~ <br />State of [-. OLO R'/~rJp County of ~/O t6LyNCD <br />Materials arc to be treed for /~ .._ _ <br />I HEREBY AGREE TO COMPLY WFFH the special conditions as set fotth below. t CERTIFY That the: (a) materials to 62 removed are 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 otthis permit; and, (d) the <br />authorized officer is to be noted upon completion of removal. <br />I CERTIFY That I am a citiun of the United Smtes, and of the age of majority in the State in which I wide. <br />I 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 />Rio B anco County <br />December 31, 2001 X ~~ ~~~ ,Commissioner <br />(Date) (Signature of Applicant) <br />Title 10. U.S.C. Suction 1001, makes it a crime for evy person knowingly and willfully:o make [o any department or agmeY of the Uniled Sfatd anyfalse,lictitious, orfraudulrnl rtatemmla or <br />r<presemations as to any matter within its juriadir~ioo. <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 wnditiom contained <br />herein are not observed. L'. shall be subject to the following spectat couditions: <br />,~~E ~ ri"J4c~Eo C_.l7uDrT/O~rrl O F t?PPr~o v.4 Ci <br />Conservation Frce:. es,r.:u!he erried out as provided'oy 43 CFR;5!LI-i(b),.2-3tc), <br />and .3-3: <br />FGuipmen[, Personal FroFr.:}'. and imppvemcnts must M removed withir. ninety (90) <br />flays i^cr cxpn-ation dzte 43 CPk Sj ;1.3-)); <br />Any nee o: the sulfa. of dr le.nds in-;oited :n this permit sha!1 5e such a: not to <br />ia~erfere vah anv r,.iniag claim vtjce:to theprovi~ion; of Secticr.4 of [he Act of July <br />23, 1555;39 U.S.C. 61 Jj; <br />The pertvittee shall clean up all work azeas and ahaB remove or dispox of all refux <br />resulting from the pcrmittee's operation; <br />This permit is issued under the Ac[ of July 31, 1947, as amrnded, and 43 U.S.C. and <br />1201, and under the free use privilege of the Act of May I4, 1898 (Alaska only). <br />An annual report indicating the amount (cu. yds. ortons) of material removed must be <br />filed with:he District Office on the anniversary date otthe permit, or within thirry(30) <br />days aJier permit expiration (Alaska only). <br />~??':%t (Signature oC.4u:horized Officer) <br /> <br />