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Fartn 5310.1 _.' f iy .. f <br />(Novemt:cr t997y UNITED STATES ~ __ _ <br />DEPARTMENT OF THE INTERIOR - <br />BUREAU QF LAND MANAGEMENT <br />tXJKht A}'PRi)VE!) <br />OMH NtJ_ 10{}4i}OOi <br />Expires; Novcmb¢r 30.2GW <br />eertntt Vumoe ~ <br />~y~ - ~ 7/ ~.'7 <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />Fxpiratian Bate <br />~~ ` ~t7 ' ~ f}Q /~ <br />APPLICATION --__, <br />Nanxe of applicant Addzcss (rnclrxle zip code) j"i' <br />G1-r~ or-` C`~t t~°/~i~ ~~~ (' R l ~'lt~ <br />Kind of material .,~ .. , _ r _ . _ . 1 <br />Give legal land <br />ic[ <br />~'h~J1J ~iT'C ~,Ct~s C. <br />~6jt- ~ n tf _~ <br />Estimated quantity <br />TOWNSHLF ~ RAfiGE. ~ SBCTIGN ~ SUOb]YtS1ON <br />/ ! ~. ~? ~ ~: /Z 2- c`f7 (.[IJx~ .JC ~ i9 7'~ ! .. Ito . <br />Statcot ~~ ~~ l~-lt~~ County of ~~~~~ <br />Materials are to be used for ~ ~ ~, ~ (.[fQ IC. I ~,,, <br />I HEREBY AGREETO COMPLY W iTH the special conditions as set forth Ifelaw. f CERTIFY That the: {aj ma[eriaL,s to be removed are to be used fot the purpose note <br />ab[n~et (b} vane of the materials removed are to be sold or bartered; Ccj rrmova7 of materials can begin otily upan receipt of an approvud Copp of this permit; aad.ld) ib <br />authorized officer is to be notified upon comptetian of removal. <br />~'P~Viot/5 ,5'J'it"vL,rfiIGAJS h~'PLy. <br />1 CEKT(PY'(hat t am a oitiun of ttte United 5txtes, and of the age of majority in the Stsee in which I reside <br />1 FURTHER CER'€IFY Thai the statements made by me in this application xn true, complete, and correct to the best otn;v knowledge and helic£ and are made in goo <br />faith. <br />Title }g U.S.C. Sec[i¢n 1001, makes it a crime foranyperson knowingly and willfully [o make to anydcpanment or agency ¢fthe United States anyfalx, fictitious, or fraudukM sL?tament5 ~ <br />rcpreuntati¢ns an to any matitt within i[s jurisdiction. <br />PERMIT <br />SPECIAL. CONDITfONS <br />This permit is haxeby issued Inr the materials applied Cor but mak he caY:eeled if it appears that Lois permit was iastned erroneously or the terms or rronditipns contains <br />herein aze not observed. It shalt be subject to the following spenal conditions: <br />Conservation ptaexices must be carried nut as provided by 43 CFft 551 1.1-i(b}, .2-3(.cJ. <br />and .3-3; <br />Equipmcnt, personat property, and improvements mrur be removed within ninety (9Q} <br />days after expimtimt date 43 CFR SS I1.3-5}; <br />Any use oC the surface of the lands involved in [his permit shall be such as aot to <br />imerfcre with any mining cfaimsubjax to xhe provisions of Secxion 4 of the Act of July <br />?3, 1955 (30 U.S.C. 613); <br />The permitter shall clean up all work areas wtd shall remove or dispose ¢f all retu. <br />resulting from the pcrmiixce's operations; <br />This permit ¢ issued untie[ the Act aC.tuty 31, 1947, as amanded, and d3 U.S.C. ,u' <br />1201, and under the €rec use privilege of the Ae[ of Map la, ig9& (Alaska onlg). <br />An annual report indieatingthe amount (etc, yds. or tons) dmaterial rc[noved must 1 <br />filed with the bistric7 Offiu nn the anniversary date oithe permit, orwithin thirty f3• <br />days after permit expiration (Alaska only}- <br />