PERMFILE120015

• Permit No: M1994092
• IBM Index Class Name: Permit File
• Doc Date: 6/20/1994
• Doc Name: BLM FREE USE APPLICATION & PERMIT VEGETATIVE OR MINERAL MATERIAL
• Media Type: D
• Archive: No

'•
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SIO-I 99y
1. .n 19ag) UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FREE USE APPLICATION AND PERMIT
VEGETATIVE OR MINERAL MATERIAL
APPLICATION
Name o(applicanl Address (inrludr :ip rode)
Fremont County 615 Macon Avenues ~(
Kind of material _ -
EORM APPROVED
OMB NO. 1004-0001
Expires: October 31. 1990
Pcrmn Number
CO-050-RG-FU-94-51
Expiration Date
5-4-99
District
~CDO
Estimated quantity .4cn nhn
TOWNSHIP ~ RANGE ~ SECTION ~ SUBDIVISION
19S 72W 32 Tract 47 S'~
State of ~ County of
Colorado Fremont
Materials arc to he used for
Road base
HEREBY AGREE TO COMPLY W ITH the special conditions az set forth below. I CERTIFY That the: (a) materials to be removed arc to be used for the purpose noted
above; (b) none of the materials removed arc to be sold or bartered; (c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the
authorized officer is to be notified upon completion of removal:
1 CERTIFY That 1 am a citizen o(the United States, and of the age of majority in the State in which I reside.
1 FURTHER CERTIFY That the statements made by me in this application are true, complete, and Correct to the best of my knowledge and belie(and are made in good
faith.
(Date) (Signature of
Title I B U.S.C. Section 1001, makes it a crime (or nny penon knowingly and willfully to make to any department or agency of the Unfired States any false, fictitious, or freudulens statements or
rtpresenwions ss so any matter within iu jurisdiction.
PERMIT
SPECIAL CONDITIONS
This permit is hereby issued for the materials applied for bur may be canceled if it appears that this permit waz issued erroneously or the terms or conditions contained
herein arc not obxrved. It shall be subject to the following special conditions:
Attached
Information is collected to comply with Statutes (16 U.S.C. 604-606 and agenty Regulations (dJ CFR 5611.1-I(f)).
Information is used to confirm the residence of the applicant.
Applicant mart respond to obtain a permit.
Conservation practices mart be carried out az provided by 43 CFR SS I I.I-1(b), .2.31<).
and .3-l: a
Equipment, personal property, and improvements must be removed within ninesy (90)
days alter expirasion date 13 CFR SSI 1.3-61:
Any use of the surface of the lands involved in this permit shall be such as not to
i nmrfere wit h any mining claim subject ro t he provisions of Section 4 0(the Act of July
23, 1953 (30 U.S.C. All):
The permisree shall clean up ell work areaz and shall remove or dispose of all rcfux
resulting from the permitstt's operations;
This permit is issued under she Act of lulu 31, 1947, as amended. and 43 U.S.C. and
1201, and under th<free use privilege of the Acs of May 14, 18981Alaska only).
An annual report indicating the amount (cu. yds. or tons) of mamnal removed must be
Oled wnh the Drssrin OfGe! on the anniversary date of the permit, or wnhm rhirq~ f30/
days gJrer pcrmis expiration (Alaska only)
~^ IDate) ISignamrc of Authonrcd OfGcerl
APPLICANT