Laserfiche WebLink
5LF; Li i <br />Form 5510-1 <br />(August 2007) UNITED STA AUG 27 PM 2= 43 <br />DEPARTMENT 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 />OMB NO. 1004-0001 <br />Expires: March 31, 2010 <br />Permit Number <br />COC73801 REFUGE #1 <br />Expiration Date <br />09/21/2019 <br />District <br />LSFO <br />Name of applicant Address (include zip code) PO BOX 667 <br />MOFFAT COUNTY FOAD DEPARTMENT 822 E. 1ST STREET <br />CRAIG, CO 81626-0667 <br />Kind of material SAND AND GRAVEL Estimated quantity 50 OOOCY <br />Give legal land description <br />TOWNSHIP RANGE SECTION SUBDIVISION <br />1ON 103W 10 SWSW <br />state of COLORADO I County of MOFFAT <br />materials are to oe used for RESURFACING COUNTY ROADS <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 />Bureau of Land Management (BLM) must be notified upon completion of removal. <br />I CERTIFY'rhat 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 t the best of my knowledge and belief and are made in good <br />faith. <br />(D te) (Signature of cant) <br />Tide 19 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 will be subject to the following special conditions: <br />SEE EXHIBIT A, SPECIAL STIPULATIONS <br />Conservation practices must be carried out as provided by 43 CFR 5511. 1- l(b),.2-3(c), <br />and.3-3; <br />Equipment, pal 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 must not interfere with <br />any mining claim subject to the provisions of Section 4 of the Act of July 23, 1955 <br />(30 U.S.C. 613); <br />The permittee must clean up all work areas and must remove or dispose of all refuse <br />resulting from the penmittee'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 tots) of material removed must be <br />filed with the District Office on the anniversary date of the permit, or within thirty (30) <br />days af)er permit expiration (Alaska only). <br />(Date) (Signature of BLM) <br />(Continued on page 2) APPLICANT <br />Q FIELD OFFICE