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~-. -- ~-• ~ - s j RECEiHEQ 'rL1Y 2 9 1B9U <br />Form SSlO-I <br />(March 1988! <br />~,:.:.,~ ~ ~ 14.00 <br />UNITED STATES _ <br />DEPARTMENT OF THE lNTERIO&:~~~~=='=` == '° "' ~'- <br />BUREAU OF LAND MANAGEMENT --- - _ -~ <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />FORM .4PP2UVED <br />_ 019 VO. it7~W-0001 <br />- .~ Expires 9ctober 91. 1990 <br />Permit Number <br />COC 51366 <br />Expiration Date <br />Distncl <br />APPLICATION Montrose <br />Name of applicant Address (mr/ude _rp ruder <br />San Miguel County Road Department Box 426 Norwood CO 81423 <br />kind of material Estimated quamity <br />Gravel 30 000 c <br />Grve legal land description <br />TOtYNSHIP RANGE SECTION SU BDI~ISION <br />43N 16W 9 E} NW} SWz <br />state u( Colorado Counnof San Miguel <br />Matenals are to be used for <br />County Roads <br />I HEREBY AGREE TO COMPLY WITH the special conditions as set lonh below. 1 CERTIFY Thal the: la) materials to be removed are lobe med (or the purpose noted <br />above:) bl none oCthe materials removed are to be sold or bartered: (cl removal of malrnals can begin only upon receipt o(an approved ropy of ihu perms: and.Idl tht <br />amhorved oficer is so be notified upon eomplelion of removal <br />I CERTIFI' That 1 am a r~tizen of the United States, and of the age ofmajority in the State in which 1 reside. <br />I Fh RTHER CERTIFI' That the statements made by me in this application are Irur, complete, and correct to the best o(m}' knouled¢e and belie) and are madt in good <br />faith <br />March 22, 1990 ~~~ ~?~J4.2// <br />(Date) ~ (Signature of Applicant) <br />Tule 18 CS C Section 1001. makes n a crime (or any person knowingly and willfully tomake roan} depanmem or agency of the Uniud Stain, any false. funmm. or Irautlulem vmemem+nr <br />rrpreseniauom a> to any maser within its junsdmtion. <br />PERMIT <br />SPECIAL CONDITIONS <br />Thts permit is hereby issued for the materials applied (or but may be canceled i(it appears that this permit was issued rrroneousty or the terms or conditions comamed <br />herein are not observed. It shall be subject to the following special conditions: <br />ATTACHED <br />Information is collected to comply wuh Statutes 116 U.S.C. 604-606 and agency Regulm ions (43 CFR 551 LI-I(Q1. <br />Information rs used to conCtrm th< residence o(the applicam. <br />Applicant must respond to obtain a permit. <br />Comervauon practices must be carved out as provided b} 41 CFR 551 L I-Ilb).. ~-?(c). <br />and .?-?: <br />Equipment, personal property, and improvements must be remos ed within inset} 1901 <br />days alter ex puation date 43 CFR 551 L?-51: <br />Ant use u( the surface of the lands m•'olved in this permu shall be such as nm to <br />inmrfere wuh am mining claim sublect to the provision>o(Secuon4 0l the Act aCJuly <br />?3. 1955 UO U.S.C. 6U): <br />5 -as <br />(Date) <br />The p<rminee shall clean up all work areas and shall remote nr dispose o(all eel use <br />resulting Irom lh< permntee•s operations, <br />This permit ¢ ¢sutd under the Aa o(luly i I. 1947, as amended. and 43 U $ C and <br />I?01, and under the free use prisilege o(tht Aa of May l4. 189g (Alaska only). <br />An annual repon indicating theamount fcu. yds or rons)of material removed rnun he <br />filed wnh the Dtstnct Office on the anniversary dat< o(the per inn. or wuhin ihi.rr (?0) <br />days after permu eapimtion (Alaska only) <br />ure of Authorimd Office <br /> <br />•mer ....i.s <br />