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<br />Form 5510.1 FORM APPROVED <br />(July 1993) UNITED STATES Exhibit N (page 1) OMB NO. 1004-0001 <br />DEPARTMENT OF THE INTERIOR Expires: May 31, 1996 <br />BUREAU OF LAND MANAGEMENT Permit Number GLA`G PVT ?Z.,.4 <br />FREE USE APPLICATION AND PERMIT Expiration Date <br />VEGETATIVE OR MINERAL MATERIAL 04' zo Q 151 <br />District <br />APPLICATION I GrA 1C? <br />Name of applicant Address include zip code) po ec) 'X? <br />V\ O6:AT (-w i?IT`f CL Vt rAgi ?,S I ON -P-S aeA [G.; Lc7 (? <br />Kind of material L Estimated quantity ?9 QOM t?? <br />Give legal land description <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />State of CO LiO)Z-/3c Do County of <br />Materials are to be used for <br />50E -r-AC-0Q161 P ADC-[C?kT Cwt) ICY 2? ??S <br />I HEREBY AGREE TO COMPLY WITH the special.conditions as set forth below. I CERTIFY That the: (a) materials to be removed are to be used for the purpose noted <br />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; and, (d) the <br />authorized officer is to be notified upon completion of removal. <br />I CERTIFY That I am a citizen of the United States, and of the age-of majority in the State.in which I reside.. <br />I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief and are made in good <br />faith. 1 <br />At <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false, fictitious, or fraudulent statements or <br />representations as 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 if it appears 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 />SEC- A-tTAC-OMEi-q <br />Conservation practices must be tamed out as provided by 43 CFR 5511.1-1(b), .2-3(c), <br />and .3-3; <br />Equipment, personal property, and improvements must be removed within ninety (90) <br />days after expiration date 43 CFR 5511.3-5); <br />Any use of the surface of the lands involved in this permit shall be such as not to <br />interfere with any mining claim subject to the provisions of Section 4 of the Act of July <br />23, 1955 (30 U.S.C. 613); <br />a? <br />The permittee shall clean up all work areas and shall remove or dispose of all refuse <br />resulting from the permittee's operations; <br />This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. and <br />1201, and under the free use privilege of the Act of May 14, 1898 (Alaska only). <br />An annual report indicating the amount (cu. yds. or tons) of material removed must be <br />filed with the District Office on the anniversary date of the permit, or within thirty (30) <br />days after permit expiration (Alaska only). <br />??? . sl-? 6 9. z©o a) <br />(Date) (Signature of Authorized Officer) <br />APPLICANT <br />Exhibit N (p?Z?pe 1)