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.. <br />~mm 55101 <br />fMay i96s) U\ITED STATES <br />DEPARTME\T OF THE INTERIOR <br />BUREAU OF LAND MANAGEMENT <br />FREE USE APPLICATION AND PERMIT <br />VEGETATIVE OR MINERAL MATERIAL <br />APPLICATION <br />FORM APPROVED <br />OMH ~O. IUOa-0001 <br />Expires: October il. 1987 <br />Permit Kumber <br />T-'~-co-OlN-z-90 <br />Expiration Datc <br />,o-2y-4 <br />District <br />Cca~c, <br />~amr of applicant Address linrludr cip rode) <br />P.O. Box 667 <br />Kind o(material Est~maled quantity 150/Q~~ YDS <br />SAND 8 GRAVEL <br />Giw repot land description FCT10N r r OF TH r OFFAT OUNTYr _ <br />TOw'SSHIP I RANGE I SECTION I _ SCROt\'ISIOA' <br />lON 103W 10 <br />SW8SW8 METES 8 BOUNDS <br />~ SEE EXHIBIT A ATTACHED) <br />State of r. _, ,,~._,~ County of MnrraT <br />Materials ere to be ustd (or <br />Rnen IIF\/FI nPMFRT Me TFplel C <br />1 HEREBY AGREE TO COMPLY W ITH the special conditions as set forth below. I CERTIFY That the (a) materials to be rcmovcd are to be used for the purpose noted <br />above; (b) none o(the materials removed arc to be sold or bartered: (c) removal of mamrials can begin only upon receipt of an approved copy of this permit; and, (d) the <br />authorized o(icer is to be noti(i<d upon completion of removal. <br />I CCRTI FI' That I am a cif i>cn of the United States, and of the age of majority in the State in which I reside. <br />1 FORTH F.R CER i1FYThctt the statcmcnts made oy me in this application are true, complete, and correct to the best of my knowledge and belief and arc made in good <br />faith. <br />OCTOBER lI/ 1989 <br />(Date) <br />FFA <br />OAD~HEPARTMENT <br />Tide I N U S C Sen ion 1001, makes it a come for any prrson knowingly and wnlllully to make to an)' drpanmem or agency of flit Uni¢d Stems any false, fimirious, or fraudulem statrmrnts or <br />reprornutions as to am' mat¢r within its jurisdraion. <br />- PERMIT <br />SPECIAL CONDITIONS <br />This permit is hneby issued for the materials applied for buI may be canceled if it apptars that This permit was issued erroneously or the Terms or conditions contained <br />herein are not observed. It shall be subject to the following special conditions: <br />See £sdnk~.3r~ ~, a~uc~nPc~ - - <br />Information is collected to comply with Statutes (16 U.S.C. h04-e06 and agency Regulations (43 CFR 5511.1-1(Q). <br />Information is used to confirm the residence of the applicant. <br />.4pphcam must respond to obtain a permit. <br />Consenanon granites must be carried out as provided by d3 CFR 551 L L I(b), <br />.2-?Ic), and .3-J: <br />Equipment, personal properly, end improwmc ms must be removed within <br />ninety 1901 days alter expiration date 4J CFR 5511.3-5): <br />Am use of the surface o! the lands im'oh'ed in this pcrmir shall be such as not to <br />interfere with arts' mining claim subject to the pro\'tsions o(Section4 of the Act of <br />July' 23. 1955 f?0 U.S.C. 613); <br />The permittee shall clean up all work areas and shall remove or dispose of all <br />afuse r<suhing from the permiltee's operations; <br />This permit is issued under the A<t o(July' 31, 1947, as amended, and d3 U.S.C. <br />and 1201, and under the free use privilege of the Act of Al ay 14, 18961 Alaska). <br />An annual report indicating the amoum (cu. yds. or tons) of ma¢rial rcmovcd <br />must be filed with the Disvict Office on the anniversary date of the permit, or <br />w~ilhip rhirr s• (30) days afirr pcrmir expiration. <br />^ J ~, <br />//I/' )Y/ <br />J~ S ~7 ~7 <br />( ate) -~ (Sgnamre of Authorized Officer) <br />APPLICANT <br />