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. .. <br />Perm ulal <br />Pay 1~> UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VE(3ETATNE OR MINERAL MATERIAL <br />APPLICATION <br />Name of apptiuat Addreu (include zip code) <br />N1vF~A i CvV ~`! R~R~ kPA~~M(uvT Fb ~h (,o~~ , CSI G-I, [~ 81(t:2(o <br />]{ind of material PIT 2 v r1 SAN A + f~ PJr.1 F L; 21 P (Lh P Estimated quantity (oo, oc;o G y <br />- PDRM APPxovPD <br />obm No. laps-pool <br />6pitw: May 33,19% <br />Ptrmit Number <br />P..ws.u, r'arc <br />API~1L 10, 2Jt~ <br />TOWNSHIP I RANGfi I SfiCfION I SUBDIYL4ION <br />q(~ I I N iu ~ v- ~ Zia 33 ~~. ziS 5~~. ~~~~5bv~ ~ sFC, 33 <br />~~SE~ Stiv~ NyNw.)} ~Iwt~r <br />Nw~ C-.~ NN <br />State of - GU L U (~-A pl7 - - - County of M D FF/~? <br />Materia4 as w be used for SU 12~FAGl NL~ (~I-= Cut1 ~7 `{ Q O A fj S <br />I HHREBY AGRHHTO COMPLY WITH the spedal wnditiom as net forth below. I CfiitTIFY That the. (a) materials to bb removed are to be used for the purpose noted <br />above; (b) rope of the materials removed aro to be sold orbartered; (c) removal ofmateriala can begin only upon receipt of an approved copy of this permit; and, (d) the <br />authorized ofiar is to be notified upon completion of removal. <br />1 CERTIFY That I am a dtiraa of the United States, and of the age of majority in the State in which I reside. <br />I FURTHER CERTIFY That the statemenh made by me is this application are true, wmplete, and correct to the bat of my knowledge and belief and are made in good <br />faith. <br /> <br />of APPhcant) <br />Title 18 U.S.C SeUion 1001, makes h scrims foraay pertaulmowiagly and wi11fu0y to mate toTay deputmrnt or agency oftheUaitcd Staes anyfslse, ficdtiom, orfrwdWent rtatemwn or <br />mpreeatauom as m any maser wiWm iR jmisdictlou. <br />PERMIT <br />- SPECWtLCON[NTIIN+S <br />Thu permit is hereby issued for the materials plied for bm maY be cantxkd if it appeae that thin permit was issued erroneously or the tervu or condition contained <br />herds are not observed. It ahaE be subject to the following spend condition: <br />Cyr Ai ~ACtitP+~~~j A ~C-[,1P,L STIPtJ l,A-t4ot.iS <br />.~ <br />Comervatioa practice mrm becartied out u provided by43 CFR 5511.1-1(b),.2-3(c), <br />sad .3-3; <br />E9WP~t. penoaal ProPetY. sad imProvemen4 naatr be removed withiu ainuy (90) <br />days after expiration due 43 CFR SSI1.3-5j; <br />Any me of the sarfaa of the lauds involved is thin permit shall be such u uo[ to <br />iuterfem with my ntiuing claim subject to the provision otSection 4 of the Act of JWy <br />?3, 1953 (30 U.S.C 613); <br />The permittee shall clew up all work seem and shall remove or dispox of all rcfux <br />rcsWting from the permiueek operation; <br />Thin permit is issued order the Act of JWy 31, 1947, u amended, and 43 U.S.C. and <br />1201, and under the flee use privilege of the Act of May Id, 1898 (A:mka only). <br />M annual report indicatiugthe amour[ (cu. yds. or tom) of ma[erial removed mLLSr be <br />Filed with tht INstriu Otfia os the aunivenary date of the permit, pr within c5:rr~ (JO) <br />days afrrr permit expiration (Alaska ody). <br />8 <br />.l --~- <br />r ~ q <br />~ ~ L <br />e of Authorized <br />DIRTRIr:T tleFlr`C <br />