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I t r~(:Er,V'~® ~..?a.~ ? 2002 Form 5510.1 (November 1997) UNITED STATES R?YAL G^^- ~ ^ _LC DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT FREE USE APPLICATION AND PERMIT VEGETATIVE OR MINERAL MATERIAL APPLICATION FORM APPROVED OMB NO. 10040001 rues: November 30, 2000 Permit Numbe ~IJC-(6x9'8 Expiration Dale Tljnl vkP.y .S , fob r/ ~~ Name of applicant /+~ Address (include zip code) l~leC-MbNT (.odrUr !.S /~JA-Go,V A'~r ,vo~U ~,i (;~1 $1212 Kind of matcriai ~~uD ~~ /'~~~EL_ Estimated quantity 2p ~~ ~~~ TOWNSHIP ~ RANGE I SECT]ON ~ SUBDIVISION T'~f9rt/ Rrl~ Z N~y~ti~% State of 7~ G- O p ~0 ~ County of tp ~e ~ D ~l/ Materials are to be used for rl ~ ~ ~D ~ y~ ~LG ! , / ~ - I HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CER7IFY That the: (a) materials to be removed are to be used for the purpose noted 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 authorized officer is to be notified upon completion of removal. I CERTIFY That 1 am a citizen of the United States, and of the age of majority in the State in which I reside. 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 faith. (Date) (Signature of Applicant) °~~~~ Title l8 U.S.C. Section 1001, makes it acrimefor any person knowingly and wdUully[o make[o any department or agency ofthe Uni[edS[ales any false, fictitious, orfraudulen[statements or I rcprcsenmtions as to any matter within its jurisdiction. PERMIT SPECIAL CONDITIONS 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 herein aze not observed. It shall be subject to the following spectal conditions: 1) Follow Soil Conservation Service Reclamation Plan per letter to Fremont County dated December 11, 1989. 2) Use seed mix recommended by Colorado Div. of Mins. & Geology per letter to Fremont County dated May 14, 1990. 3) High walls are not authorized. Maintain natural surface profiles as closely as possible during mining activities. Conservation practices must be carried out as provided by 43 CFR 5511.1-1(b), .2-3(c), and .3-3; Equipment, personal property, and improvements must be removed within ninety (90) days alter expiration date 43 CFR 5511.3-5); Any use of the surface of the lands involved in this permit shall be such as not to interfere with any mining claim subject to the provisions of Section 4 of the Act oFJuly 23, 1955 (30 U.S.C. 613); The permittee shat) clean up all work areas and shall remove or dispose of all refuse resulting from [he permittee's operations; This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. and 1201, and under the free use privilege of the Act of May 14, 1898 (Alaska only). An annual report indicating the amount (cu. yds. ortons) of material removed must be filed with [he District Office on the anniversary date otthe permit, or within thirty (30) days after permit expiration (Alaska only). ~' ~~-/~-OZ of Authorized APPLICANT