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Form 5510.1 (Jaly 1993) UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT FREE USE APPLICATION AND PERMIT VEGETATIVE OR MINERAL MATERIAL APPLICATION Name of FORM APPROVED OMB NO.1004-0001 ixpires: May 31, 1996 L Expiration Date OS-D6 -20/S~ District Address (include zip code) S7 O - Z ~°f S~'~'P~E%~ Kind of material ~ Estimated quantity /iyJ „_ y ~ , Give legal land description TOWNSHIP RANGE SECTION SUBDIVISION Tzs ,C piu~ 3 6 sws'c~ stare of /y~L~ G~~~ cnnnty of ~io P~-.~.UGd Materials are to be used for I HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (a) materials [o b8 removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered; (c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the authorized officer is to be notified upon completion of removal. I CERTIFY That 1 am a titian of the United States, and of the age of majority in the State in which I reside. I FURTHER CERTIFY That the statements made by me in this apphcation are true, complete, and correct to the best of my knowledge and belief and are made in good faith. -l F~-~ ~' (Date) Tide IB U.S,C. Section 1001, makes it a crime for any person knowingly and willfully to make to any departm<m or agency ofthe United States anytalse, fictiaous, orfraudWem statemeau or representatiom as to any matter within its jutisdiclion. PERMIT SPECIAL CONDITIONS This permit is hereby issued for the materials applied for but maY be canceled if it appears that this permit was issced erroneously or the terms or conditions contained heroin are not observed. I[ shall be subject to the following spectal conditions: iQ~~,ta~,~L Conservation practices must becarried out as provided by43 CFR 5511.1-1(b),.2-3(c), end .3-3; Fgtapment, personal property, and improvements must be removed within ninety (90) days after expiration date 43 CFR 5511.3-5); Any use of the surface of the Inds involved in this permit shall be ¢uch az not to interfere with any mining claim subject to the provisions of Section4 of the Act of JWy 23, 1955 (30 U.S.C. 613); S6~ .dl-TT/S~"l,~Ss7 G'Du®iTlo~.sOF The permittee shall clean up all work areas and shag remove or dispose of all refuse restating from the permi[tce's operations; This permit is issued under the Act of JWy 31, 1947, as amended, and 43 U.S.C. and 1201, end under the frx use privikgc of the Act of May 14, 1898 (Alaska only). An amual report indicating the amount (cu. yds. or tons) of material removed mrvr be filed with [he District Office on the anniversary date o[the permit, or within thirty (30) days after permit expiration (Alaska otay). of Authorized APPLICANT