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<br />PURCHASER <br />OLDCASTLE SW GROUP, INC DBA <br />l1 N'ITk:D COMPANIES OF MESA COUNTY <br />(Individual or Finn Name) <br />P.O. Box 3609 <br />CIUNn Junetlon, Colorado 81503 <br />(Address) <br />UNI ED STATES OF AMERICA <br />By i I <br />( rize tcer) <br />FIELD MANAGER <br />(Title) <br />~/~ 3/0 ~- <br />(Date) <br />If you are a corporation, affix corporate seal here. <br />Title I H U.S r. Section 1001, makes it a crime for any person knowingly or willfully to make to any department or agency of the <br />United Stases any false, fictitious or fraudulent statements or representations as to any maser within its jurisdiction, subject to a <br />fine of up to 510,000 and imprisonment up to 5 years. <br />NOTICE <br />The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 <br />et seq.) requires us to inform you that: <br />BLM is collecting this information to process your <br />application and effect a binding contract. <br />BLM will use this information to identify and <br />communicate with applicants. <br />You must respond to this request to get a benefit. <br />A federal agency may not conduce or sponsor, and <br />you are not required to respond to, an information <br />collection which does not have a currently valid <br />OMB control number. <br />AUTHORITY: 30 U.S.C. 601 er seq,; 43 CFR 3600 <br />PRINCIPAL PURPOSE: BLM uses this information to <br />identify the parties entering into contracts for disposing of <br />mineral materials. <br />ROUTINE USES: BLM will transfer information from the <br />record or the record itsel(to appropriate federal, state, local, <br />or foreign agencies, when relevant to criminal, civil, or <br />regulatory investigations or prosecutions. <br />EFFECT OF NOT PROVIDING INFORMATION: If you <br />do not provide this information to BLM, we will no[ be able <br />to process your application for a contract. <br />BLM estimates the public reporting burden for this form at <br />an average of 30 minutes per response, including the time for <br />reviewing instructions, gathering and maintaining data, and <br />completing and reviewing the forts. Direct comments <br />regarding the burden estimate or any other aspect of this <br />form to U.S. Department of the Interior, Bureau o(Land <br />Management, Bureau Clearance Ofiicer, (1004-0103), <br />1849 C St., NW., Mail Stop 401 LS, Washington, D.C. <br />20240. <br />BLM MANUAL Rel. Date: <br />970-243.4900 <br />(Phone Number) <br />