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Frrm~i510-I <br />(Much 19RR)~ <br />~ -- <br />I~~ ~~~~~~~I~111~~~~ ~ <br />UNI~I'Ell S'I'A"I'Eti <br />DEPARTMENT OF THE IN'TFRIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />APPLICATION <br />Montrose <br />Name of applicant Address (include zip code) _- <br />J at U • COO/t r.rl .S'i/ C <br />Kind of material Estimated quantity QUO ~-la c <br />/OD' ~ r -7(rw o fie } <br />Give legal land description <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />"7" ~a I,1 R. 6 w. ~ 9 Neer ErcKw 7or/A sr~~ » / bfv~ o+° Eore/~n /++t, o.V or u~w.^ <br />Ufd Sin sfd~ m}II S'rf~ OH pron~r•+y ocu •v rwNd ~p•~<e! ~byy <br />SEyg Ntu~ly$6y~WnsA}.ry pN Miwi u•y nf•~ SM/TMN CO. >'rsiM.J~y 1/tN-frrnG. Ilh•.~rkr <br />e' w iN Co• ~ o D' <br />Slate of ~ r J County of r_ t- _ , <br />FORM APPROVED <br />U M B NU. I W4-0U01 <br />spires: October 31, 1990 <br />Permit Number <br />COC 50623 <br />Expiration Date <br />3-15-95 <br />hf arerials arc to be used for q <br />/ /'DAd bAS~ ar/fJel. -Fo (.Wq~~e ANf /L°sorJl+cC .SAN ~rWJ C2, Yo•va.r 'y..Z_ ~y '•o2i <br />I HF.R ERY AGREE TO COMPLY W Il H the special conduions as scr lurtb hcluw. I (~I It1lFY'fhat nc~' (a) m:ucria is m be removed are w be used fur tlm purpose nomd <br />above; (b) none o[ the materials removed are to be sold or bartered; (c) removal of materials can begin only upon receipt olan approved copy of this permit, and, (Jl nc~ <br />authorized officer is to be notiRed upon completion of removal. <br />1 CERTIFY That 1 am a citizen of the United Slates, and of the age of majority in the Stale in which I reside. <br />I FURTHER CERTIFY Thal iht statements made by me in this application arc trot, complete, end correct to the best o(my knowledge and belief and afe made in good <br />faith. <br />5~~~~H /6~'~ /99D <br />~-' (Date) <br />Title 13 U.S.C. Section 1001, makes it a crime (or any person k nowingly and willfully rn make to any depanmem m agency of thr U sited Slates any fake, fictitious. or fraudulent slaremenn or <br />represemalions u to any matter within its 7urisdnaion. _ _ <br />~- --~ PERMIT <br />SPECIAL CONDITIONS <br />This perms is hereby issued fur the materials applied for but may be canccleJ if a appcun that ibis permit was issucJ crroneumly or the icon ar cunJ stuns cunlaineJ <br />herein are not observed. It shall be subject to the following special conditions: <br />Information is collected to comply with Slar ides (16 U.S.C. 604-606 and agency Regulations (43 CFR 5511.1~1(i)). <br />Information is used to confirm the residence o(lhe applicant. <br />Applicant must respond to obtain a permit. <br />Conservation pracuces mutt be carried out as provided by 47 CFR 551 L I-I(b), .2-1(d, The permiuee shall clean up all work areas and shall remove or dispose of all refuse <br />and .J-7; resuhmg from the permitlee's operations. <br />Equipment, personal property and improvements must be removed within ninety(90) This permtl is issued under the Acl o(July 31, 1947, as amended. and 41US.C. and <br />days after expiration date 43 CFR $511.7-5): 1201. and under the free u.se privilege of the Act o! May 14, 1898 (Alaska only). <br />Any use of the surface of the lands involved in This permtl shall be such as our w 4n:uumal rcpurt muicating the amount (cu yds. ur tonal ul material temoeeJ roust be <br />interfere with any miningcluim sub)ect to the provision ofSsunnb u(Ihv An nfJuly LkJ with the Distrin OlGce on the anniversary dale of the perms, or within rhinr~(JO) <br />2J, 1955170 U.S.C. 617); deys n/ier permit expiration fAlaska only). <br />s/~y/ fo ~ ACTI NCi <br />T~ r~-= <br />^~ (Dine) < (}ilgnatur of Aulhonttd Officer) <br />APPlJCAMT <br />