Form 10-930q Special Park Use Application/Permit – Quarry Activities

NPS Form 10-930? NEW OMB Control No. 1024-0026

National Park Service Expiration Date 11/30/2023

SPECIAL USE APPLICATION / PERMIT – PIPESTONE QUARRYING Pipestone National Monument 36 Reservation Ave Pipestone, MN 56164 507-825-5464 Ext 213

The permittee is prohibited from giving false information; to do so will be considered a breach of conditions and be grounds for revocation of the permit [36 CFR 2.32(a)(3)]. Members of a federally recognized tribe means any tribe, band, nation, or other organized group or community of Indians, including any Alaska Native village (as defined in, or established pursuant to, the Alaska Native Claims Settlement Act (43 U.S.C. 1601 et seq.)), recognized as eligible for the special programs and services provided by the United States Government to Indians because of their status as Indians by its inclusion on the list of recognized Indian Tribes published by the Secretary under the Act of November 2, 1994 (25 U.S.C. 5131).

Quarry Permittee Information

Name:

Address:

Telephone: ( ) Email:

Are you an enrolled member of a federally recognized tribe? Tribal Affiliation:
Yes / No

Permit Type (Circle One): Calendar year (annual) – Monthly - Weekly

Verification of Enrollment for issuance of permit under 36 CFR 7.42

Additional Quarriers (if needed)

1	2
Name:	Name:
Address	Address:
Tribal Affiliation:	Tribal Affiliation:
3	4
Name:	Name:
Address:	Address:
Tribal Affiliation:	Tribal Affiliation:

Issuance of this permit is subject to the attached conditions. The undersigned acknowledges they have read the attached conditions and hereby accepts this permit subject to the terms, covenants, obligations, and reservations, expressed or implied herein.

Permittee	Authorizing NPS Official
Signature:	Signature
Printed Name:	Title:
Date:	Date:
Assigned Quarry Location:	Permit Expiration Date:

PERMIT CONDITIONS

1. his permit may not be transferred or assigned without the prior written consent of the Superintendent.
   
   

2. The permittee shall exercise this privilege subject to the supervision of the Superintendent or designee, and shall comply with all applicable Federal, State, county and municipal laws, ordinances, regulations, codes, and the terms and conditions of this permit. Failure to do so may result in the immediate suspension of the permitted activity or the revocation of the permit. All costs associated with clean up or damage repairs in conjunction with a revoked permit will be the responsibility of the permittee.
   
   

3. The permittee is responsible for making all necessary contacts and arrangements with other Federal, State, and local agencies to secure required inspections, permits, licenses, etc.
   
   

4. The park area associated with this permit will remain open and available to the public during park visiting hours. This permit does not guarantee exclusive use of an area. Permit activities will not unduly interfere with other park visitors’ use and enjoyment of the area.
   

5. This permit may be revoked at the discretion of the Superintendent upon 24-hour notice.
   
   

6. The permit may be revoked without notice if damage to resources or facilities occurs or is threatened, notwithstanding any other term or condition of the permit to the contrary.
   
   

7. This permit is made upon the express condition that the United States, its agents and employees shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, injuries, or death to any person or persons or property of any kind whatsoever, whether to the person or property of the permittee, its agents or employees, or third parties, from any cause or causes whatsoever while in or upon said premises or any part thereof during the term of this permit or occasioned by any occupancy or use of said premises or any activity carried on by the permittee in connection herewith, and the permittee hereby covenants and agrees to indemnify, defend, save and hold harmless the United States, its agents, and employees from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits or losses however occurring or damages growing out of the same.
   
   

8. The person(s) named on the permit as in charge of the permitted activity on-site must have full authority to make any decisions about the activity He/she shall be responsible for all individuals, groups, vendors, etc. involved with the permit.
   
   

9. Nothing herein contained shall be construed as binding the Service to expend in any one fiscal year any sum in excess of appropriations made by Congress or administratively allocated for the purpose of this permit for the fiscal year, or to involve the Service in any contract or other obligation for the further expenditure of money in excess of such appropriations or allocations.
   
   

10. If any provision of this permit shall be found to be invalid or unenforceable, the remainder of this permit shall not be affected, and the other provisions of this permit shall be valid and be enforced to the fullest extent permitted by law.

11. The Superintendent shall designate the site where the permittee may, during the term of the permit, quarry pipestone. In the absence of the Superintendent, other monument staff will assist with the quarry designation. The assigned site will be listed on page 1 of this permit.

12. This permit is issued for the length of time indicated on the front page. All calendar year permits expire on December 31.

13. No fee or other charges shall be made for the issuance of this permit. A copy of this permit will be furnished to the permittee upon issuance.

14. It is the responsibility of the permittee to renew their annual permit by April 1. Due to the high demand for quarry permits, this procedure will be strictly followed. Quarry activities may not occur after December 31 of the calendar year if the permit is not renewed.

15. Only American Indians enrolled in federally recognized tribes as included in the publication of list of recognized tribes 25 U.S.C. 5131, may be involved in the quarrying process. Written proof of tribal enrollment is required of the permittee and additional quarriers. Verification of enrollment will be checked and copies maintained for monument records. Copies will be securely destroyed when the permit expires.

16. The permittee, or quarriers authorized to work in the quarry, are required to sign-in at the Visitor Center information desk prior to each day’s work. In the event there has been no sign-in during the preceding year the permit will not be renewed.

17. The quarrying of Pipestone is an inherently dangerous activity, requiring exercise of caution during all phases. Accidents during quarrying involving injury can and do happen. In accepting this quarry permit, permittees assume all risk and responsibility for the personal safety of themselves and all others working with them.

18. In the case of an emergency, Call 9-1-1. All permittees are required to report to any accident to a park ranger.

19. Equipment used in the quarrying operation may include but not be limited to the following hand tools: shovels, picks, wedges, pry-bars, sledgehammers, wheelbarrows, and brooms. Any tools powered through electricity or other fuels are prohibited in the quarrying process.

20. The permittee is responsible for securing their stone from theft by removing quarried slabs or pieces as soon as possible.

21. When quarrying, if the permittee should encounter artifacts such as arrowheads, stone knives, scrapers, chipped stone tools, mauls, hammer stones, pottery, worked pipestone pieces, or other buried or surface artifacts, please cease quarrying and leave the objects in place. Immediately contact the Superintendent or one of the park rangers. Once the items are documented by the monument staff, quarrying can resume.

22. Monument maintenance staff must be notified two days in advance of arrival for a quarry to be pumped of groundwater. Due to liability and safety issues, permittees are prohibited from using personally owned pumps or accessories for pumping groundwater from the quarries. During periods of high groundwater, particularly during the spring and early summer, the monument may elect not to pump the quarries. Please call the monument for water level conditions and schedule quarrying accordingly.
    
    

23. The sale of raw pipestone is prohibited within the boundaries of Pipestone National Monument.

NOTICES

IMPORTANT NOTICE TO APPLICANT

If your request is approved, a permit containing applicable terms and conditions will be sent you. The permit must be signed by the responsible person and returned to the park for final approval by the Park Superintendent before the permitted activity may begin.

Customers Making Payment by Personal Check

When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day we receive your payment, and you will not receive your check back from your financial institution.

Privacy Act Statement

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing this application.

Authority: The authority to collect information on the attached form is derived from 54 U.S.C. 100101.

Purposes and Uses: The information being collected to allow the park manager to make a value judgment on whether or not to allow the requested use. Information from the application may be transferred to appropriate Federal, State, and local agencies, when relevant to civil, criminal or regulatory investigations or prosecutions.

Effects of Nondisclosure: It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison or both. Deliberately and materially making false or fraudulent statements on this form will be grounds for not granting you a Special Use Permit

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers with the information needed to decide whether or not to allow the requested use. All applicable parts of the form must be completed in order for your request to be considered. You are not required to respond to this or any other Federal agency-sponsored information collection unless it displays a currently valid OMB control number.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 15 minutes per response including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 13461 Sunrise Valley Drive Reston, Virginia 20192. Please do not send your form to this address.

INTERNAL AGENCY USE ONLY

Project Number/BILL:

Date Processed:

Permit Number:

Prepared By:

Organization Name:

Page 1 of 4

RECORDS RETENTION: Unapproved (3 years).  Maintain Approved applications with related permit and associated records based on appropriate item(s) in NPS Records Schedule 1, Resources Management and Lands, (N1-79-08-1)