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./ <br />Form s5161 FURM APPAOV(37 <br />(~aly 1993) UNITED STATES OMB NO. I004-0ODl <br />DEPARTMENT OF THE INTERIOR EaP~~ ~Y 3I, 1996 <br />BUREAU OF LAND MANAGEMENT Permit Number <br />FREE USE APPLICATION AND PERMIT Expiration Date <br />VEGETATIVE OR MINERAL MATERIAL <br />District <br />APPLICATION ~~ I ~o <br />Name o(applicant Addrcst (mcfude zip code) P.o . /30 ~C K K , S 70 2 "' : <br />Io~LAaco ~au't"f ~o~A 5 ~R-tDGc Pk-f~ ~-~-KC-fL ~ <br />Kind of material ~ Estimated quantity <br />Give legal land description <br />TOWNSNIP RANGE SECTION SUBDIVISION <br />T Z S~ fZ l OkfJ Sti 3~ _ P~r~r o F S w 5 ~v <br />'T-' 3~ t ~. 10 f W S.ac. ~ - PART O F C.O T 8 To T/} ~- q~~ ~2L-Qi <br />State of ~. ^ ~o ~ ~ D b Cormty of !J ~ ~N ~ <br />lXJ 1` l O <br />Materials arc to be wed for ~ f~D g to (ZFPt-e(NCo <br />I HEREBY AGREE TO COMPLY W ITH the special conditiow a xt forth below. I CERTIFY Thu the: (a) materials ro b! removed are to be uxd (or the purpose noted <br />above; (b) none of the materials removed arc to be sold or bartered; (c) removal of materials cm begin only upon receipt of an approved copy o(this permit; and, (d) the <br />authorized ofirxr is to be notJed upon completion of removal. <br />1 CERTIFY That I am a citizen of the United States, and of the age of majority N the State in which 1 reside. <br />I FURTHER CERTIFY That the statements made by me in this applicmion are true, complete, and correct to the best o(my knowledge and belief and arc made in good <br />faith. <br />SPECIAL CONDITIONS <br />This permit is hereby issued for the materials applied for bu[ may be canceled if it appear Char this permit was issr<d cnoneowly or the terms or conditions contained <br />herein are not observed. Ir shall be subject to the fo0owing spinal conditions: <br />C(`ti~ITIe,~S cf- ~CYKo~/rrc_ d~~/1-eKK=-E~ <br />Conservxuon practices mrzsr be carried out as provided by 47 CFR 551 I.I-1(b), .2-7(c), <br />and .3-3; <br />Equipment, pcrsnnal propeny,:.nd improvements incur be removed within ninety (90) <br />days after <xp:rat;on date 43 CFR 5511.3-5); <br />.Anv are of the surface of the lands involved in this permit shall be such as not to <br />interfere with anv mining claim subject to the provisiaw o($ection 4 of the Act of July <br />23, 1955 (30 U.S.C. 61?): <br />The permittee shall clcm up all work area and shell remove or dupox of all reface <br />resulting from the permiltee's operetiow; <br />This permit is issued under [he Act of July 31, 1947, u amended, and 43 U.S.C. and <br />1201, a~ under the free ux privilege of the Act of Mey I4, 1898 (Alarka only). <br />An annual report indicating the amount (w. yds. or tow) of material removed mart be <br />Ided with the Dutriet (')Etas on the amivenary date of the permit, or within thirty (30) <br />days after perm[ eapvatioa (Alaska oWy). <br />of <br />Title 18 LL$.C. Stttioo 1001, mekea it a crime for my penon knowingly and willfully to make to any depsnmeet or agency o(the Uvited Sr•... any false, finitiow, or fraudulent rutemrnn or <br />reprerentatiom a to any matter within in jurisdiction. <br />PERMfT <br />