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Farm 5510.1 <br />(Jn1y 1993) UNITED STATES <br />DEPARTMEN":f OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OFi MINERAL MATERIAL <br />APPLICATION <br />Name of applican[ <br />Colorado Department of Transportation <br />Address (inefude zip code) <br />222 S. 6th St., Rm 317, Grand Junction, CO 81,~g <br />Kind of material Estimated quanti[y <br />Shale and sandstone 100.000 cu.vd, <br />Give legal land descnp[ion 13.32 Acres -See attached ma for metes and bounds descri tion. <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />FORM APPROVED <br />OMB NO. 1004-0001 <br />Expires: May 3l, 1996 <br />Permit Number <br />Expiration Date <br />District <br />T 3 5 R 102 W 25 W} NEB <br />6th PM <br />State of Colorado County of Rio Blanca <br />Materials are to be used for <br />maintenance of State hi¢hwavs in the ¢eneral area. <br />1 HEREBY AGREE TO COMPLY W RH the special condli[ions asset forth below. 1 CERTIFY That the: (a) materials to be removed arc to be used for [he purpose noted <br />above; (b) none of the ma[enals removed arc [o be sold or bartered; (c) removal otmaterials can begin only upon receipt of an approved copy o(this permit; and, (d) the <br />authorized officer is to be notified upon completion of removal. <br />1 CERTIFY That I am a citizen of the United States, anal of [he age oC majority N the State in which 1 reside. <br />1 FURTHER CERTIFY That the statements made by me in this application arc true, complete, and cortect to the best o(my knowledge and belie and are made in good <br />faith. <br />5l/2r /9: ~ a l~ <br />~ (Date) (Signature of Applicant) <br />Title IB U.S.C. Semion 1001, makes it acrimeforany penon knowingly and willfu0yto make to any pattment or agency ofthe United Slates any false,fictitious, or fracdulenr Statements or <br />rtprexntations az to any matter within iu juriWiction. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued Cor the materials applied for bu[ may be canceled if it appears [hat this permit was issucd erroneously or the terms or condihons contained <br />herein arc not observed. 1[ shall be subject [o the follovviog special conditions: <br />T/fs ~~pL.+c6s r~ 9-/S-9S f)PPLcu/-ioa <br />Conservation practices mrvr be tamed out az provided by 4"";CFR 5511.1-1(b),.2-3(c), <br />and .3-l; <br />Equipment, personal propcny, and improccments marl be removed within ninety (90) <br />days after expiration date dl CFR 5511.7-5); <br />Any use of the surface of the lands involved in this permi[ shall b< such az not [o <br />interfere with any mining claim subject to the provisions of Section 4 of the Act o(July <br />23, 1955 (30 U.S.C. 617); <br />The pemitttt shay clear, up all work areas and shall remove or dirpose u(all rtfuse <br />resulting from the penni;ttt; operations; <br />This permit is isaacd uuder.L•c Oct o(July 71, 1947, az amended, and d7 U.S.C. and <br />1201, and undtr the (rs use p-h'ilcge o(the .4U of May I4, 1898 (Alazka ody). <br />An annual repnr• ind.cn~ mg :he ,.mount (cu, cds. or tons) o(ma!enal remm'ed must be <br />filed a•nh the Durrct Cfi;e r n the arniva nary date of [hc permit, or within rhirfy (3C 1 <br />days alter permit eaprranon tAiaska enly). <br />a ~+;ra~i~r <br />