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<br />' Form 5510-I <br />(Murrh 1988) <br /> <br /> <br />1 <br />(• <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 />OMH NO. 1004-0001 <br />Expires: October )I, 1990 <br />Permit Number <br />COC-52699 <br />Exoiration Date <br />Name of applicant Address (include zip rode) <br />Ouray County, Colorado PO Sox C, Our.a_a, Colorado 81427 <br />Kind of material Sand and Gra¢el (Estimated quantity20,000 yds/7ca- <br />Give legal land description <br />' TOWNSHIP RANGE SECTION SUBDIVISION <br />T.45N.~, R.8W.,~ISec: 7, E~NW~NWk and WkNE~N'w}, N?tPM <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />State of, Colorado Courtly of Ouray ' <br />Materials are to be used for <br />~,... ,.... ~...,J ,.~~c., ,. ,.- ., ..A ~..1 .,. ~.t ..,.mow <br />1 HEREBY AGREE TO COMPLY WITH the special conditions az set forth below. 1 CERTIFY That the: (a) materials to be removed arc [o be used for the purpose noted <br />above; (b) none of the materials removed arc to be sold or bartered; (c) removal ofmaterials can begin only upon receipt of an approved copy of this permit; and, (d) the <br />authorized officer is to be no[i~ed upon completion ofremoval. <br />1 CERTIFY That I am a citizen o(the United States, and of the age of majority in the State in which I reside. <br />1 FL'RTH ER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my knowledge and belie(and are made in goad <br />faith. <br />(Date) (Signature o(Applicant) <br />Title 18 U.S.C. Section 1001, makes it a crime for anv person knowingly and willfully to make to any department or agency of the U sited Slates anv false, fc~itious, or fraudulent statements or <br />represemanons as to any maser within its junsdiuion. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued [or the materials applied for but may be canceled i(it appears that this permit was issued erroneously or the terms or conditions conlatned <br />herein are not observed. It shall bt subject to the following special conditions: <br />t ATTnCY,ED <br /> <br /> <br />Information is collected to comply with Statutes (16 U.S.C. 604-606 and agency Regulations (47 CFR 551 I.I-I(~). <br />Information is used to confirm the residence of the applicant. <br />Applicant must respond to obtain a permit. <br />Conservation practices mart be carried out az pronded by 47 CFR 551 I.I-1(61,.2-7(c), The permittee shall clean up all work areas and shall r<mosx or dispose of all refuse <br />and .7-7: resulting from [h< permittee's operations; <br />t Equipment, personal property, and im provements mart be removed within ninet}'(90) This permit is issued under the Act of July 71, 1947, as amended. and 43 U.S.C. and <br />days alter ex puanon date 43 CFR 5511.7-5): 1201, and under the free use privileee o(th< Act of May 14. 1898 (Alaska only). <br />Am use of the surface of the lands im olved in this permit shall be such az nor m .4n annual report indicau ng the amount (cu. yds. ortonsl n(mmerial removed must be <br />interfere wish am~mmingclaim subJecuothe proris~oro of Seaion4 of the An oUuly Gled with the Diuricl Oifice on the anniversary date of the permit. or within rhirn'/70) <br />' 27. 1955170 U.S.C. 617); days ajrer permit aspnazion (Alaska onlv).- <br />(DuU (Signature of Authorized Oificerl <br />01871iICT OFFICE - <br />