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<br />Form 55161 <br />(July 1993) <br />UNITED STAT:°' <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />APPLICATION <br />n <br />u <br />FORM APPROVED <br />OMB NO. lOlk1-1100] <br />Expires: May 31. 1996 <br />Permit Number <br />rc~C - 3 5 9C <br />Expiration Date <br />O - 06 - <br />District <br />~D ~- //O n 0 <br />Name of applicant Address (fnclude zip code) <br />R c ~~ ti~ , .~ ~P 4- rev c Bo K E~ F~ > ~~ly <br />Kind of material ~ CY ~ Estimated quantity CU 000 C <br />Give legal land description <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />y S. /cy~i /t3 sE/1/u~ ; sw NE <br />State o! / ~ ~ n~Abd County o[ k!v BG ~~~n <br />Materials arc to be used for fJ~ ~~ ~FPAi,~ d' /~ /5f/A/T~iIJ A.rIC' <br />1 HEREBY AGREE TO COMPLY WITH the special conditions u set forth below. 1 CERTIFY That the: (a) materials to be removed arc to be used for the purpose noted <br />above; (b) none o(the matenals removed are to be sold or bartered; (c) removal of materials can begin only upon receipt of m approved copy of this permit; and, (d) the <br />authorized officer is to be notified upon completion of removal. <br />I CERTIFY That 1 am a citizen of the United Steles, and o(the age of majority in the Sate in which 1 reside. <br />l FURTHER CERTIFY That the statements made by me in this application are true, complete, and corrm to the best of my knowledge and belief and are made in goad <br />(with. <br />/~ /O ~O~ <br />(Date) <br />Title 18 U.S.C. Secuon 1001, makes it a crime for any person knowingly and willfully to mete to nay depertmrnl or ageoey o(the United States my false, fictitious, or fraudulent statements or <br />reprcuntations az to nay matter within iu juritdiaion. <br />PERMIT <br />SPECIAL CONDITIONS <br />This permit is hereby issued for the materials applied for but may be canaled'd it appears that this permit waz issued ertoneotuly or the terms or conditrons contained <br />herein are not observed. It shall be subject to the following special conditons: <br />SEE ~k/Y-Ids i ~ r~ <br />Conservation practices must be carried out az provided by 43 CFR 5511.1-I(b), .2-3(c), <br />and .l-l; <br />Equipment, personal propcny, and improvements must be removed within ninety (90) <br />days after expiration date 4J CFR 5511.3-5); <br />Any use of the surface of the lands involved io this permu shall be such az not to <br />interfere with any mining claim subject to the provisions of Section 4 of the Act of July <br />23, 1955 (30 U.S.C. 613); <br />The permitltt shall clean up aH work areas and shall remove or dispose of all refuse <br />resulting from the permitttt's operatiore; <br />This permit is issued under the Act of July 31, 1947, az amended, and 43 U.S.C. and <br />1201, and under the frtt use privilege o(the Act of May 14, 1898 (Alaka only). <br />Ao moual report indicating the amount feu. yds. or tons) of material removed must lx <br />filed with the District Olfitt on the anniversary date of the permit, or within thirty (30) <br />days after permit expiation (Alaska oNy). <br /> <br />