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'U.a. GPO: lfreaa]&839/850)2 <br />Form 5510.1 <br />(July 1993) <br />UNITED STATES <br />DEPARTMENT OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />;. <br />S`>~ ~. <br />FORM APPROVED <br />OMB NO. 1004-110D1 <br />Expires: May 31, 1996 <br />Permit Number <br />Expiration Datc <br />Name of apphcant ~ r, ~ 'Address (mclude zip code) , <br />v ~ S ~'D 2'r'n r~P' 6r ~~ ~1 <br />Kind of material SA d G,e 6~ t' ~ Estimated quantity DD <br />Crive legal land description <br />TOWNSHIP RANGE SEC170N SUBDIVISION <br />//V /DZW ,g NENE <br />State of ~ County of ,,pp~~ <br />Materials are to be used for ~ , <br />iQa'~7D ~~ /~lrrinvT~NAwc6 <br />f HEREBY AGREE TO COMPLY. WITH the special conditions as se[ forth blow. I CERnFY That [hc: (a) materials to be removed are to be used for [he purpose noted <br />above; (b) none of the materials removed are to be sold of bartered; (c) removal of materials can begin only upon receipt of an approved copy of this permit; and, (d) the <br />authorized officer is to be notified upon completion of removal. <br />_ , . ~ . <br />I CERTIFY That I am a titian of the United States; and, of the age of majority inahe State in which I reside, ~ .' ^ ~ . ~ -~ <br />1 FURTHER CERTIFY That the sta Tements made by me in this application are true, complete, and wrrect to the best of my knowledge and belief aad ate made in good <br />faith. ` <br />. .. ~ r- ~ <br />' (Date) ~ ' <br />Title t8 U.S.C. Section 1001 <br />as <br />any department oragenry of the Unted States any false, fictitious, orfraudulent statements or <br />4 h„ •'PERMIT...- .. ,", v t-~ z ;ri <br />' ". SPECIAL'CONDITONS <br />This permit is hereby issued for.the materials applied for but maY be canceled if it appears [hat this permit was issued erroneously or the terms or conditions contained <br />herein are not observed. It shall be subject to the following apemal conduions: _ , , , , <br />SEE l3rl'~cH~o ~avairio.~s of /,~pPRovs~tr <br />Conservation praMices must be carried out as provided by 43 CFR SSI1.I-f(b),.2-3(c}, <br />and .3-3; <br />Equipment, personal property, and improvements must be removed within ninety (90) <br />days Nter expiration date 43 CFR 5511.3-5); <br />Aoy use of the surfatt of the lands involved in this permit shall be such as not to <br />interfere with anyminingclaim subject ro the provisions of Scetion 4 of the Act o(July <br />23, 1955 (30 U.S.C. 613); <br />io~/~ ~ <br />The permittee shall clean up all work areas and shag remove or dispose of aB refuse <br />resNting Gom the pecminee's operations; <br />This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. and <br />1201, and under the free use privilege of the Am oC May 14, 1898 (Alaska oNy). <br />An annuN report indicating the amount(cu. yds. or tans) of material removed must be <br />filed with the District Officeon theanniversarydate of thepermit, or within thirty(30) <br />days after permit expiration (Alaska only). <br />z~r.~~~. <br />