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<br />' Form 5510-I <br />(March 1988) <br /> <br /> <br />UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION 11N`D•PERMIT <br />VEGETATIVE OR MINERAL M~A,~ERIAL <br />' '~_ ~ District <br />APPLICATION Montrose <br />Name of applicant ~ Add«ss (include zip rode) <br />' Ouray Gounty, Colorado PO Box C, Our.ay, Colorado 81427 <br />Kind of material Sand and Gra¢el Estimated quantity20, 000 ydS/y•:ar <br />Give legal land description <br />' TOWNSHIP RANGE SECTION SUBDIVISION <br />r <br />T.45N., R.8W.,'Sec: 3, E~NW}NW} and WkNE}Nld}, NMPM <br />' State of, Gclorado County of Ouray <br />' Materials are to be used (or - ' F <br />..-a rc,~~.. ~...+ ~~i--.,.r ...tea <br />1 HEREBY AGREE TO COh1PLY WITH the special conditions az set forth below, I CERTIFY Thal the: (a) maledals to be removed are to be used for the purpose soled <br />about; (b) none of the materials removed arc to 6e sold or bartered; (e) removal of materials can begin only upon receipt of an approved ropy olthis permit; and, (d) the <br />' authorized officer is to be notified upon completion of removal. <br />1 CERTIFY That 1 am a citizen of the United Stales, and o([he age of majority in the Slate in which I reside. ' <br />' 1 FL'RTH ER CERTIFY That the statements made by me in [his application are trot, complete, and correct to the best of my knowledge and belief and are made in good <br />faith. <br />' ^ (Date) (Signature of Applicant) <br />Title I B U.S.C. Section 1001, makes it a came for any person knowingly and willfully to make to any department or agency of she United Stares any false, fictitious, or fraudulent sta~emen~s or <br />represemarions as so any maser within firs jurisdiction. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued for the materials applied (or 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 />1 <br />:,; T.;C N E D <br />Information is collected to comply with Statutes (16 U.S.C. 60406 and agency Regulations (43 CFR SSI1.1-I(f)). <br />Information is used to confirm the residence of the applicant. <br />' Applicant nmsr respond to obtain a permit. <br />Conscn'aiion practices mutt be carried our ss provided by 43 CFR 5511.1-1(b),.2-3(c), <br />and .3-J: <br />' Equipment, personal property, and improvements must be removed within ninety (90) <br />days after expinnon dare 4J CFR 551 L7-5); <br />1 <br />1 <br />;ii!3 _ .- <br />FORM APPROVED <br />OM B NO. 1004-0001 <br />Expues: Orxober 31, 1990 <br />Yermu Number <br />COC-52699 <br />Expiration Date <br />The permittee shall clean up all work cress and shall remote or dispose of all refuse <br />resulting from the permistee's operations; <br />This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. and <br />1.01, and under the free use privilege o(rhe Act of May 14, 1898 (Alaska only). <br />.4n annual report indicating the amount (cu. yds. ar tons) of material removed must be <br />filed with the District Office on the anniversary date of the permit, or within rhiris' (30J <br />does ajrer permit expiration (Alaska only). ~ <br />., _~~ fi-~ <br />,. . ,, <br />(Date) ~ (Si¢nature of Authorized <br />Any use of the surface of the lands involved in shin permit shall bu such as not to <br />interfere with any mining claim subject to the provisions ofSeaion4 of the Act o(July <br />2J, 1955 (30 U.S.C. 613). <br /> <br />