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- • _;<I ,. <br />' Form 5510-I <br />(March 1988) <br />1 <br />1 <br /> <br />r" r <br />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 />Expires: October 3l, 1990 <br />Permit Number <br />COC-52699 <br />Expiration Date <br />April 1, 1996 <br />District <br />Name of applicant Address (include zip rode) <br />Ouray Goun[y, Colorado PO box C, Our.a_r, Colorado 81427 <br />Kind of material Sand and Gra¢el <br />Estimated quantity20, 000 yds/yea. <br />' Give Icgal land description <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />' T.45N., R.SW.,-~Sec. 3, E~NW~IvW} and WkNE}NW}, NMPM <br />State c(, Ctlorado County of Ouray <br />' Materials are to be used (or <br />-a .-~-„-~~ ...+ mot- ,,.I ra <br />1 HEREBY AGREE TO CDAfPLY WITH the special conditions az set forth below. 1 CERTIFY That the: (a) materials to be removed are to be used for the purpose noted <br />' above;(b)none of the materials removed are to be sold or barlered;(c)removal of materials tan begin only upon receipt of an approved copy of this permit; and, (d)the <br />authorized oHccr.is to be notified upon completion of removal. <br />' 1 CERTIFY That I am a citizen o(the United Smtes, and o(the age of majority in the State in which I reside. <br />I FL'RTH ER CERTIFY That the statements made by me in this application arc true, 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 S U.S.C. Section 1001, makes it a crime for any person k nowingly and willfully to make to any department or agency of the United States any false, fictitious, or fraudulent statements or <br />represcntasions as to any matter within its jurisdiction. - <br />' PERMIT <br />SPECIAL CONDITIONS <br />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 <br />' herein are not observed. It shall be subject to the following special conditions: <br />' :iiTACNED <br />Information is collected to Comply with Statutes (16 U.S.C. 60406 and agency Regulations (43 CFR 551 I.I-I(f)). <br />' Information is used to confirm the residence oC the applicant. <br />Applicant musr respond to obtain a permit. <br />Conservation practices mart be carried out as provided by 43 CFR 551 I.I-I(b), .2-3(c), The permittee shall clean up all work arcaz and shall remove or dispose o(all refuse <br />' and .3-3: ~ resulting from the permiltee's operations: <br />Equipment,personalproperly, and improvements must b<removed within ninety (90J This permitisissued under the Act of July 71, 1947, as amended, and 43 U.S.C. and <br />days a(I<r expiration date 43 CFR 5511.3-5): 1201, and under the free use privilege of the AcI of May 14, 1898 (Alatka only). <br />Any use of the surface of the lands invohtd in this permit shall bu such as not to .4n annual report indicating the amount feu. yds. or tons)of material removed musr be <br />inmrfem with any mining claim subjento the provisions o(Sccrion4 of the Act-ofJuly filed withthe District O((¢a on the anniversary date o(the permit Or within rhinr/30J <br />23, 1955 (30 U.S.C. 613): days after permit expiration (Alaska only). ~ <br />_' -r. <br />(Date) (Signature of Authorized Officer) <br /> <br />