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Form 5570-1 i •' UNITED~TES :. U~;' :,': ,'i~~, it°°y 1972) DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEDf~NT FREE USE APPLICATION AND PERMIT VEGETATIVE OR MINERAL MATERIAL G i . r.. .. ... FOR!! APPROVED OMB NO. 42-R0875 Permit Number 050 0- - E:piralion Date Feb. 17. 199 District APPLICATION Name of applicant Address (include rip code) Kind of material ~ I Estimated quantity' Pit Pun or Crushs~ Peck - inn_nnn r.,, ~,~~ TORNSH[P I RANGE 1 SECTION I S1raONISION _ __ 1iN. 101. 28 « 33 P,T # ~ ~ Sacs 2S, ~~~ ~+:; v :~ JZ J~y SL'/1} Sec. 33 ~ N~ N4t'~ P°:3 T°.': y Ira i:.: 4. Materials are to be used for o~:fa~ing on County Roads I HEREBY AGREE TO COMPLY WITH the special conditions as set forth below. I CERTIFY That the: (e) materials to be removed are to be used for the purpose noted above; (b) none of the materials removed are to be sold or bartered; (c) removal of materials can begin only upon receipt of an approved copy of this permit; andt (d) the authorised •officer is to be notified upon completion of removal. ; `'. s' ~t' '~ ~ ~~ =~ ~.+ ~1 - I CERTIFY That I am twenty-one years of age or older, a citizen of the United States, and resident of the State of Colorado I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my Imowledge and belief end ere made in good faith. 2/i 7/"J ~ ~ ~~` :fir'"-~/ ~.~~ (3uy~ervi sox (Dale) ~ ~ (Signature of Applicant) Title 18 U.S.C. Section 1001, makes SI R crime [or any person knowingly and willfully to make to aay department or ageory of the United States any .[else, fictitious, or fraudulent statements" or representetlona •a to any matter within Ste jurisdiction. '. ''~ ~ .. PERMIT SPECIAL CONDITIONS ~ ~ ~ This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was j issued erroneously or the terms or conditions contained herein are not observed. It shall be subject to the following_ :` special conditions; ~ A See A7~gc~ied .S~iee.~ ~~ Conservation practices must be practiced as provided 'The ,permittee..shall clean up' all work areas and shall by 43 CFR SSll.i-1(b), .2-3(c), end .3-3; -. _ _. Temove or dispose of all refuse -resalting from-the Equi~dt~,~,~rsona7~~property, and improvements must- - permittee's operations;-i.'.:~_'."_ ,.; .., .a _.,, ,, -.a be removed within ninety (90) days after expiration ~ y date (43 CFR 3621.3(c) or 5511.3-5); This permit is issued under the Act of July 31, 1947, as emended, and 43 U.S.C. 2 and 1201. Any use ,of the surface of the lands involved in this permit shall~be such as not to interfere. with eny~mining-. _. ., _ _ _ claim subject to the provisions of Section 4 of the Act ~ ~ ~ ' of July ?3, 1955 (30 U.S.C. 613); , - _ .... .. , ,~r,. .. s/z ~~>s~ ~ _ _ _ ~_~~(Date) ~ ~ ~ ~' (Signature A Norized Off'cer) ~ ~~