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'Form 5510-1
<br />(November 1976)
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<br />Atla,•Ilr~,l :ra "l'.°411.1( A" crmsisl inf) oP tvto pArlcs n; lr, ;tirl~i.,~ i;,ir~,
<br />•.i OcCObr.r fig 19811,
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<br />Conservation practices must be practiced as provided
<br />' by 43 CFR 5511.1-1(b), .2-3(c), and ; 3-3;
<br />j ~ Equipment, personal property, and improvements must
<br />be removed within ninety) (90) days after expiration
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<br />UNITED STATES '
<br />DEPARTMENT OF TfiE INTERIOR
<br />BUREAU OF LAND MANAGEMENT
<br />FREE USE APPLICATION AND PERMIT
<br />VEGETATIVE OR MINERAL MATERIAL
<br />Exp'rretion Dete
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<br />District ~
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<br />Name of applicant Address (include zip code)
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<br />Kind of matecial Estimated quantity
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<br />Give legal land description _
<br />TOWNSHIP RANGE SECTION SUBDIVISION
<br />f`~J.~: Ri'):1 il; tit o `,tl'.;
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<br />S",; 'ioxi:;r, f'I•incil'.11 Ilcl•i~li,'ll
<br />State o[ I'nlnl-,r 11) , . County of. 14~';n
<br />Materials are to be used for ,
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<br />1 HEREBY AGREE TO COMPLY WITH the special conditions es set Iortft below. 1 CBRTIPY Thet tlte: (e) malarial[[
<br />to be removed are to be used for the purpose noted above; (b) none of the materlela removed are to be sold or bettered;
<br />(c) removal of materials can begin only upon receipt of en approved copy ofthfa peRnlt; and, (d)th~ authorized o(fjcer
<br />is to be notified upon completion of removal. ~ '
<br />I CERTIFY That I am twenty-one years of age or older, a citizen of the United,Stetes, end resident of the State of
<br />FIIRTH6R CERTIFY That the at9teflleflte made by me !tl tJIIY applicatioq are true, complete, end correct to the best
<br />of my {(rlowlsdga pnd baljef and rrra mods In good faith.
<br />11C5,'t hn.uilty ft clad I)eparlnl•-n l:
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<br />~~~ _:-.i (~') ... ~ tr I ., ~ .:.. 1'.tll~~~.. ~` tl')Il!C)rT~l •... ~ i .., ~ ..-. 111'
<br />(Uele) '' (Slgneture of Appllcenl)
<br />Title l6 U.6.C. Secllon 1001, mekee 11 a crime (or any person knowingly end willfully to make to any department or agency of the
<br />United States any false, flclitioue, or fraudulent etetemente or representations es to any matter within its jurisdiction.
<br />' PERMIT
<br />~~ SPECIAL CONDITIONS
<br />This permit is hereby issued for the materials applied for but may be canceled i( it appears that this permit was
<br />issued ertoneously or the terms or conditions contained herein are not observed. It shall be subject to the following
<br />special conditions: ~ ~ ~ ~~ ~ ~ I
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<br />7'he permittee shall clean up all work areas and shall ,
<br />remove or dispose of all refuse resulting Lrom the I
<br />permittee's operations; ~ '
<br />date (43 CE'R 3621.4(c) or 5511.3-5); This permit is issued under the Act of July 31, 1947,
<br />r as amended, and 43 U.S.C. 2 and 1201.
<br />Any use of the surface o[ the lands involved in this
<br />permit shall be such as not to interfere with any mining An annual report indicating the amount (cu. yds. or tons)
<br />claim subject to the provisions of Section 4 of Lire Act of material removed must be filed with the dis-
<br />oF July 23, 1955 (30 U.S.C. 613); tricl office of the anniversary date of the permit, or
<br />within tl+irry (30) days a/tar permit expiration.
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<br />(Uelr) ~ (S iv nature of Authorized Utfrce!)
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<br />FORM APPROVED
<br />OMB NO. 42-R0875
<br />Permit Number `
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