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r l~ ~ l ~ <br />Form 5510-I UNITED STATES <br />(November 1976) DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEh1ENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />APPLICATION <br />Name of applicant <br />.. .. .. ..: crt-.~ <br />Kind of material <br />.._.... .t -. _._ .. <br />ion <br />-• r; <br />SV HUIV 1JlU1V <br /> <br />State of County of <br />Materials are to be used for _. <br />I HEREBY AGREE TO C011PLY IVITH the special conditions as set forth below. I CERTIFY That the: (a) materials <br />to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered; <br />(c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the authorized officer <br />is to be notified upon completion of removal. <br />I CERTIFY That I am twenty-one years of age or older, a citizen of [he United States, and resident of the State of <br />I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best <br />of my knowledge and belief and are made in good faith. <br />- _ .i <br />'(Date) ~ ~ (8t gnature of Applicant) <br />Title IB U.S.C. Section 1001, makes it a crime for any person knowingly and willfully [o make Io any department or agency of the <br />Vni,ed States ony false, fic Utiou s, or fraudulent state menu nr :epresenlations as to any matter avithm its jurisdiction. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was <br />issued erroneously or [he terms or conditions contained herein are not observed. I[ shall be subject to the following <br />special conditions: <br />.. ... ,. ons ...~.:,c:~r~:. <br />Conservation practices must be practiced as provided <br />by 43 CFR 5511.1-1(b), .2-3(c), and .3-3; <br />Equipment, personal property, and improvements must <br />be removed within ninety (90) days alter e>piration <br />date (43 CFR 3621.4(c) or 5511.3-5); <br />Any use of the surface of cite lands involved in this <br />permit shall be such as not to interfere with any mining <br />claim subject to the provisions of Section 4 of [he Act <br />of July 23. 1955 (30 U.S.C. 613); <br />The permittee shall clean up all work areas and shall <br />remove or dispose of all refuse resulting from the <br />permittee's operations; <br />This permit is issued under the Act of July 31, 1947, <br />as amended, and 43 U.S.C. 2 and 1201. <br />An annual report indicating the amount (cu. yds. or tons) <br />of material removed m« st be filed with the dis- <br />Irict office of the anniversary date of the permit, or <br />within rl+i rty (?0) days n/[er permit expiration. <br />::7.. /. l ~i . <br />(Date) / j' / (Signature o[rAuthorized Officer) <br />APPLICANT <br />J ~ .. .... i._.._'..;~ <br />FORM APPROVED <br />OMB NO. 42-R0875 <br />Permit Number <br />Expiration Date <br />District <br />,t. ~ . r <br />Address (include zip code) <br />Estimated quantity <br />