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~~ <br />Form 551(41 <br />(July 1993) UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />FY1RM APPROV® <br />OMB NO. 1004-0BBl <br />3xpircs: May 31, 199ti <br />Number <br />Date <br />District <br />APPLICATION C(Z ~' I <br />NameQQof applicant~l [~ R~~ pp~~ ~~ ~~ Address (include zip code) ~n A~ .. ~~O )C K K , ~fS~~O Z N D. <br />IOLr-~WCO l.o4NT'C IL014i~ 5 VWpCE Jx~i' 1 ~ LC~--KL~- ~J <br />Kind of material Estimated quantity <br />SUBLIIYIS[ON <br />T r S, fZ t okAl sti 3~ - PA~7" o F S w S w <br />'F' '3 ~ , fZ t o r w S~ l - Pl~rLz o F [~o T 8 -r-D -r~ ~- q , ~ .AE-~c-~ <br />Stau of /' ... _ _. ~ a _ ~ .. County of /) Q . .d.... _ <br />Materials sue to be used for p~ ,~ ,gyp - G3 ~ R~~e f N (o <br />I HEREBY AGREE TO COMPLY WITH the special condition asset forth below. I CERTIFY That the: (a) materials to b! removed are to be used for the purpose noted <br />above; (b) none of the materials removed are to be sold or bartered; (c) removal of materials can begin ody upon receipt of an approved copy otthia permit; and, (d) the <br />authorized officer is to be noted upon completion of removal. <br />I CERTIFY That I am a tti[izen o[ the Unittxt Stmes, and of the age of majority in the State in which I reside. <br />I FURTHER CERTIFY That the statements made by me in this applicazion are true, compiete, and correct to the bat of my knowledge and belief and are made in good <br />faith. <br /> <br />of <br />Title) 8 U.S.C. Sermon I W I, makes i[ a crime formy pmon knowingly and willfully to make to anydepartmen[ or agency of the United State anyfslse, fic[itiom, orfraudulcnt autements or <br />rcPrcsentadom as to anY muter within in jurisdiction <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued for the materials applied fm but may be canceled if it appear that this permit was issued erroneously or the terms or conditions contained <br />herein are not observed. It shag be subject to the following special conditions: <br />C c~ ruc>I TI ~ S e f- Pt G' f ~0~)~1-~ >~~ei-e ~l-c~ <br />Conservation practices mnrr be carried out as provided by43 CFR 5511.1-I(b),.2-3(c), <br />and .3-3; <br />Equipment, personal property, and improvements mrurbe removed within ninety (90) <br />days after expsation date 43 CFk 551 L3-5); <br />Any use of the surface of [he lands involved in this permit shall be such as not to <br />interterc with soy mining claim subjem to the provisions of Sertion 4 of [he Act of JWy <br />23, 1955 (301Ja.C. 6I3): <br />-~-=~=' <br />(Date) <br />The permitter shag clean up all work areas and shall remove or dispox of all refuse <br />raWting from the permrtter'a operations; <br />1tis permit u issued under the Act of JWy 31, 1947, as amended, and 43 U.S.C. and <br />1201, and under the frer rue privilege of the Am of May 14, 1898 (Alaska only). <br />An amual report indira[ingthe amount(cu. yds. ortoas) of material removed must be <br />fded with the District ~er oa the anniversary date of the permit, or within thirty (30) <br />days after permit expiration (Alaska only). <br />of <br />