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„F ., <br />r op ,, ~. ~ <br />Form s5lal v~~ ~ U CG~J <br />(November 1997) UNITED STATES '^- - .. <br />DEPARTMENT OF THE INTERIOR ~ "` ' ~ _=~ ~ ~ ~'~ <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />APPLICATION <br />FORM APPROVED <br />OMB NO. 1004.0001 <br />Expues: November 30, 2000 <br />Permit Numbe <br />~'OG'- ~o7/~r7 <br />Expiration Date <br />D9 - 3O -zoo ~ <br />Distritt .,, <br />2Prnlo,v G~i rEf-D orF <br />Name of applicant I Address (include sip rode) P v BOjZ ~3 0 <br />C r ry ~ ~'6, r i0[ F CR aEEti' ~R 1 P/LE C/1 £E.C ~ CO 8~S/3 <br />Kind of material '>rb~a/n l~-/ n ~/ 1JE D... Ectimatcd quantity <br />TOWNSHIP I RANGE I SECTION ~ SUBDIVISION <br /> <br />State of ~ L D /L¢ p 0 - County of - -~-Le LL E2 <br />Materials arc to be used Cor ~ D ~ D ~4.J0 /C /~ <br />I HEREBY AGREE TO COMPLY W ITH the special conditions as set forth below. I CERTIFY That the: (a) materials to be ttmoved att lobe used for the purpose notW <br />above; (b) none of the materials removed are to be sold or bartered; (c) removal otmaterials can begin only upon receipt of an approved copy of this permi[; and, (d) the <br />authorized oftar is to be noticed upon completion o[ removal. <br />j~/ir<VIOUS STiP(/~rrrDAis gi~~y, <br />I CERTIFY That I am a titian of the United Stales, and of [he age of majority in the Stale in which I reside. <br />1 FURTHER CERTIFY That the statements made by me in this application are we, wmpku, and correct to the best of my knowledge and belief and are made in good <br />faith. <br />Title IB U.S.C. Stttion 1001, mats it aerimc for any person knowingly wad willfully w make to aaydepanateot or ageaq oftbe Uoited Statesaoy falu, fiaidous, orftaudukm ststcmcnts or <br />rtprescntadon as m any matter within its jurisdittioo. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued Cor the materials a peed for but maY 6e car:alW if it appears that this permit watt issued erroneously or the terms or conditions contained <br />herein are not observed. It shall be subjett to the following specal eondnion: <br />Conervadon practices mart be carried out n provided by 43 CFR 5511.1-1(b),.2-3(c), <br />and .3-3; <br />Equipment, personal property, and improvements mutt be removed within ninety (90) <br />days after expiruioo date 43 CFR 5511.3.5); <br />Any use of the surface of [he lands involved in this permit shall be such as not to <br />intcrfcrc with any mining claim subject to the provision of Section 4 of the Att of July <br />II, I95S (30 U.S.C. 613); <br />9-z y o3 <br />(Date) <br />The pcrmi[ta shall ckan up all work areas and shall remove or diapox of ell rcfusc <br />resulting from the pcrmittee's operation; <br />This permit rs issued under the Att of July 31, 1947, n amended, and 63 U.S.C. and <br />1201, and under the fra use privilege of the Att of May 14, 1898 (Alaska ody). <br />An annual reportindicating[he amomt(cu. yds. or ton) oCmatcrial removed mart b< <br />filed with the Distritt OSra on the ennivenary date of the permit, or within rhvey (30) <br />days ofrn permit expiration (Alaska ody). <br />(Sigost of Authorired O sat) <br />