2010-04-28_PERMIT FILE - M2010024

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Form 5510-1 FORM APPROVED (August 2007) UNITED STATES OMB NO. 1004-0001 DEPARTMENT OF THE INTERIOR Expires: March 31, 2010 BUREAU OF LAND MANAGEMENT Permit Number COC-71890 FREE USE APPLICATION AND PERMIT Expiration Date VEGETATIVE OR MINERAL MATERIAL 10/15/2019 District APPLICATION CO-110 Name of applicant Address (include zip code) Rio Blanco County Road and Bridge 570 Second Street Spring Creek Gravel Pit Meeker, CO 81641 Kind of material Sand and Gravel, Clinker (524) Estimated y quantity 250,000 c Give legal land description TOWNSHIP RANGE SECTION SUBDIVISION 1N 100W 6 NENW, NWNE 2N 100W 31 SESW, SWSE State of Colorado I County of Rio Blanco Materials are to be used for Construction and maintenance of county roads 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 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 Bureau of Land Management (BLM) must be notified upon completion of removal. 1 CERTIFY That I am a citizen of the United States, and of the age of majority in the State in which I reside. 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 faith. I O 3 -2,009 ?. `e, (Date) (Signature of Applicant) 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 representations as to any matter within its 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 issued erroneously or the terms or conditions contained herein are not observed. It will be subject to the following special conditions: See attached Rio Blanco County Srping Creek Gravel Pit Conditons of Approval Conservation practices must be carried out as provided by 43 CFR 5511.1-1(b),.2-3(c), and.3-3; Equipment, personal property, and improvements must be removed within ninety (90) days after expiration date 43 CFR 5511.3-5); Any use of the surface of the lands involved in this permit must not interfere with any mining claim subject to the provisions of Section 4 of the Act of July 23, 1955 (30 U.S.C. 613); (Date) The pennittee must clean up all work areas and must remove or dispose of all refuse resulting from the permittee's operations; This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. and 1201, and under the free use privilege of the Act of May 14, 1898 (Alaska only). An annual report indicating the amount (cu. yds. or tons) of material removed must be filed with the District Office on the anniversary date of the permit, or within thirty (30) days cater permit expiration (Alaska only). of BLM) (Continued on page 2) XJ APPLICANT ? DISTRICT OFFICE