+---------------+-------+---+-----+------+---------+--------+--------+
| **UNITED      |       |   |     |      | *       |        |        |
| STATES**      |       |   |     |      | *Permit |        |        |
|               |       |   |     |      | No.**   |        |        |
| **DEPARTMENT  |       |   |     |      |         |        |        |
| OF THE        |       |   |     |      |         |        |        |
| INTERIOR**    |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| **BUREAU OF   |       |   |     |      |         |        |        |
| RECLAMATION** |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| **SPECIAL     |       |   |     |      |         |        |        |
| EVENT         |       |   |     |      |         |        |        |
| PERMIT**      |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| Instructions: |       |   |     |      | *       |        |        |
| Complete      |       |   |     |      | *Please |        |        |
| Items 1       |       |   |     |      | Type Or |        |        |
| through 8,    |       |   |     |      | Print   |        |        |
| and return to |       |   |     |      | Plainly |        |        |
| appropriate   |       |   |     |      | In      |        |        |
| Reclamation   |       |   |     |      | Ink**   |        |        |
| Office. *(Use |       |   |     |      |         |        |        |
| additional    |       |   |     |      |         |        |        |
| sheets, if    |       |   |     |      |         |        |        |
| necessary.)*  |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **WHEN SIGNED |       |   |     |      |         |        |        |
| BY AUTHORIZED |       |   |     |      |         |        |        |
| RECLAMATION   |       |   |     |      |         |        |        |
| OFFICIAL,     |       |   |     |      |         |        |        |
| THIS PERMIT   |       |   |     |      |         |        |        |
| AUTHORIZES**  |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **1. Name of  |       |   | **  |      |         |        |        |
| contact       |       |   | Add |      |         |        |        |
| person and    |       |   | res |      |         |        |        |
| Or            |       |   | s** |      |         |        |        |
| ganization:** |       |   | *(i |      |         |        |        |
|               |       |   | ncl |      |         |        |        |
|               |       |   | ude |      |         |        |        |
|               |       |   | zip |      |         |        |        |
|               |       |   | c   |      |         |        |        |
|               |       |   | ode |      |         |        |        |
|               |       |   | )*: |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **Telephone   |       |   | **F |      |         |        |        |
| No.**         |       |   | ax: |      |         |        |        |
| *(include     |       |   | (   |      |         |        |        |
| area code)*:  |       |   | )** |      |         |        |        |
|               |       |   |     |      |         |        |        |
| **Daytime: (  |       |   | *   |      |         |        |        |
| )**           |       |   | *Em |      |         |        |        |
|               |       |   | ail |      |         |        |        |
| **Evening: (  |       |   | A   |      |         |        |        |
| )**           |       |   | ddr |      |         |        |        |
|               |       |   | ess |      |         |        |        |
| **Day of      |       |   | :** |      |         |        |        |
| Event: ( )**  |       |   | \_  |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   |     |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
|               |       |   | \_\ |      |         |        |        |
|               |       |   | _\_ |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **2. Name or  |       |   |     |      |         |        |        |
| legal         |       |   |     |      |         |        |        |
| description   |       |   |     |      |         |        |        |
| of the event  |       |   |     |      |         |        |        |
| location**    |       |   |     |      |         |        |        |
| *(attach      |       |   |     |      |         |        |        |
| map)*:        |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **3. Provide  |       |   |     |      |         |        |        |
| a full        |       |   |     |      |         |        |        |
| description   |       |   |     |      |         |        |        |
| of the        |       |   |     |      |         |        |        |
| activity or   |       |   |     |      |         |        |        |
| event         |       |   |     |      |         |        |        |
| including     |       |   |     |      |         |        |        |
| number of     |       |   |     |      |         |        |        |
| anticipated   |       |   |     |      |         |        |        |
| participants  |       |   |     |      |         |        |        |
| and           |       |   |     |      |         |        |        |
| spectators:** |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **4. Time and |       |   |     |      |         |        |        |
| date the      |       |   |     |      |         |        |        |
| event will    |       |   |     |      |         |        |        |
| occur**       |       |   |     |      |         |        |        |
| *(specify     |       |   |     |      |         |        |        |
| below)*:      |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **START**     |       |   |     | **E  |         |        |        |
|               |       |   |     | ND** |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **DATE**      | **T   |   |     | **DA |         | **     |        |
|               | IME** |   |     | TE** |         | TIME** |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| (Mon., Day,   | AM    | P |     | (M   |         | AM     | PM     |
| Yr.)          |       | M |     | on., |         |        |        |
|               |       |   |     | Day, |         |        |        |
|               |       |   |     | Yr.) |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
|               |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **5. Describe |       |   |     |      |         |        |        |
| the           |       |   |     |      |         |        |        |
| facilities,   |       |   |     |      |         |        |        |
| including     |       |   |     |      |         |        |        |
| sanitation    |       |   |     |      |         |        |        |
| facilities,   |       |   |     |      |         |        |        |
| emergency     |       |   |     |      |         |        |        |
| personnel,    |       |   |     |      |         |        |        |
| food          |       |   |     |      |         |        |        |
| services, or  |       |   |     |      |         |        |        |
| vendors you   |       |   |     |      |         |        |        |
| intend to     |       |   |     |      |         |        |        |
| provide**     |       |   |     |      |         |        |        |
| *(attach      |       |   |     |      |         |        |        |
| plans and     |       |   |     |      |         |        |        |
| location      |       |   |     |      |         |        |        |
| map)*:        |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| **6.**        |       |   |     |      |         |        |        |
| Certification |       |   |     |      |         |        |        |
| of            |       |   |     |      |         |        |        |
| Information:  |       |   |     |      |         |        |        |
| [I            |       |   |     |      |         |        |        |
| certify       |       |   |     |      |         |        |        |
| ]{.smallcaps} |       |   |     |      |         |        |        |
| that the      |       |   |     |      |         |        |        |
| information   |       |   |     |      |         |        |        |
| given by me   |       |   |     |      |         |        |        |
| in this       |       |   |     |      |         |        |        |
| application   |       |   |     |      |         |        |        |
| is true,      |       |   |     |      |         |        |        |
| complete, and |       |   |     |      |         |        |        |
| correct to    |       |   |     |      |         |        |        |
| the best of   |       |   |     |      |         |        |        |
| my knowledge  |       |   |     |      |         |        |        |
| and belief    |       |   |     |      |         |        |        |
| and is given  |       |   |     |      |         |        |        |
| in good       |       |   |     |      |         |        |        |
| faith. I      |       |   |     |      |         |        |        |
| acknowledge   |       |   |     |      |         |        |        |
| that I (we)   |       |   |     |      |         |        |        |
| am (are)      |       |   |     |      |         |        |        |
| required to   |       |   |     |      |         |        |        |
| comply with   |       |   |     |      |         |        |        |
| any           |       |   |     |      |         |        |        |
| conditions or |       |   |     |      |         |        |        |
| stipulations  |       |   |     |      |         |        |        |
| that are      |       |   |     |      |         |        |        |
| required by   |       |   |     |      |         |        |        |
| the           |       |   |     |      |         |        |        |
| authorized    |       |   |     |      |         |        |        |
| officer when  |       |   |     |      |         |        |        |
| the permit is |       |   |     |      |         |        |        |
| issued.       |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| (Signature of |       |   |     |      |         |        |        |
| Applicant)    |       |   |     |      |         |        |        |
| (Date)        |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| 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 |       |   |     |      |         |        |        |
| re            |       |   |     |      |         |        |        |
| presentations |       |   |     |      |         |        |        |
| as to any     |       |   |     |      |         |        |        |
| matter within |       |   |     |      |         |        |        |
| its           |       |   |     |      |         |        |        |
| jurisdiction. |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+
| This          |       |   |     |      |         |        |        |
| application   |       |   |     |      |         |        |        |
| is hereby     |       |   |     |      |         |        |        |
| approved      |       |   |     |      |         |        |        |
| subject to    |       |   |     |      |         |        |        |
| the           |       |   |     |      |         |        |        |
| conditions    |       |   |     |      |         |        |        |
| and special   |       |   |     |      |         |        |        |
| stipulations  |       |   |     |      |         |        |        |
| on reverse    |       |   |     |      |         |        |        |
| and any       |       |   |     |      |         |        |        |
| attachments.  |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| (Signature of |       |   |     |      |         |        |        |
| Authorized    |       |   |     |      |         |        |        |
| Official)     |       |   |     |      |         |        |        |
| (Date)        |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| Date entire   |       |   |     |      |         |        |        |
| application   |       |   |     |      |         |        |        |
| received:     |       |   |     |      |         |        |        |
| \             |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
| \_\_\_\_\_\_\ |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
| Date use fee  |       |   |     |      |         |        |        |
| received:     |       |   |     |      |         |        |        |
| \_\_\_\_\_    |       |   |     |      |         |        |        |
| \_\_\_\_\_\_\ |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
|               |       |   |     |      |         |        |        |
| Date          |       |   |     |      |         |        |        |
| insurance     |       |   |     |      |         |        |        |
| received:     |       |   |     |      |         |        |        |
| \             |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
| \_\_\_\_\_\_\ |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
| Amount of use |       |   |     |      |         |        |        |
| fee received: |       |   |     |      |         |        |        |
| \_\_\_\_\_    |       |   |     |      |         |        |        |
| \_\_\_\_\_\_\ |       |   |     |      |         |        |        |
| _\_\_\_\_\_\_ |       |   |     |      |         |        |        |
+---------------+-------+---+-----+------+---------+--------+--------+

+-----------------------------------------------------------------------+
| **PERMITTEE MUST HAVE THIS PERMIT** *(OR LEGIBLE COPY)* **IN          |
| POSSESSION**                                                          |
|                                                                       |
| **DURING USE IN PERMITTED AREAS.**                                    |
+-----------------------------------------------------------------------+

**PERMITS SUBJECT TO THE FOLLOWING CONDITIONS**

*(The conditions and stipulations required by the authorized officer are
**checked below**.)*

**The following shall be submitted 45 days before an application is
approved and a permit issued. Special Use Permits, where applicable,
shall be issued subject to:**

 a. A topographic map, showing area of proposed use with routes,
parking, staging areas, proposed improvements, and other points of
intensive use specifically identified.

 b. Applicant will inform other pertinent private landowners and/or
public agencies *(law enforcement, highway, fish and game, etc.)*.

 c. A certificate from an insurer that liability insurance has been
obtained for this use or event in the minimum amount of \$1,000,000 for
personal injury and property damage for any one occurrence. The
certificate shall also state that Reclamation its employees, agents, and
assigns be named as additional insured and that such insurance is in
force. The insurer will notify Reclamation a minimum of 7 days in
advance of cancellations or modifications of such insurance.

 d. An acceptable bond, surety, cash deposit, or other acceptable
guarantee of payment to secure payment of the special use fee and/or
mitigation of damages may be required.

 e. The permit is issued for the period specified. It is revocable for
any breach of conditions hereof or in the event of a disaster or
unforeseen emergency at the discretion of the Park Manager or authorized
representative. This permit is subject to valid adverse claims
heretofore or hereafter acquired.

 f. This permit is subject to all applicable federal, state, and local
regulations. Permittee will provide a copy of all necessary permits for
the event (food services, Fish and Game, etc.).

 g. This permit may not be reassigned or transferred by permittee.

 h. Permittee will notify the authorized officer of address change
immediately.

 i. Permittee shall pay the United States for any damages to its
property resulting from this use.

 j. Permittee shall abide by all stipulations and/or restrictions that
apply to the conditions of the permit.

 k. Permittee will provide for traffic control associated with the
event at the discretion of the Park Manager who may require a written
traffic management plan. Permittee shall not restrict roads, trails or
waterways commonly in public use, except as authorized within this
permit.

 l. Authorized representatives of the Department of the Interior, and
other Federal, state and local agencies must at all times, have the
right to enter the premises on official business.

 m.Vehicles and watercraft associated with the event will obey all
federal, state, and local laws and ordinances, and will be operated and
parked in areas designated by the Park Manager or authorized
representative.

 n. Permittee shall maintain area and dispose of any waste associated
with their activities and leave the area as it was found prior to the
activity. Permittee will be responsible for proper disposal of all waste
and shall keep the premises in a neat, orderly and sanitary condition
during the event. Permittee may be required to provide sanitary and/or
refuse facilities and may be required to dispose of refuse offsite as
specified by the Park Manager.

 o. Permittee shall take all reasonable precautions to prevent forest,
brush, and grass fire of lands. A written fire prevention plan may be
required at the discretion of the Park Manager.

 p. Permittee shall take all reasonable precautions to prevent
contamination or pollution of waters on or within the permitted area.
Substances causing contamination or pollution shall include but are not
limited to hazardous materials, thermal pollution, refuse, garbage,
sewage effluent, industrial waste, petroleum products, misused
pesticides and containers, or any other pollutants.

 q. No structures may be constructed or altered unless specifically
authorized or approved in writing, no digging or excavating is
permitted, no shrubbery or trees or any other flora, are to be cut,
trimmed or injured. No additions, alterations, modifications, or
decorations may be affixed or erected without specific written approval
of the Park Manager or authorized representative. No painting or
attachments using spikes, stakes, tacks, or pins to the pavement or
signs.

 r. Permittee hereby agrees to indemnify and hold harmless the United
States, its employees, agents, or assigns from any loss or damage and
from any liability on account of personal injury, death, property
damage, or of any nature caused by any person, firm, or corporation
arising out of the Permittee's activities under this permit.

 s. Permittee shall not disturb archeological and historical values,
including, but not limited to petroglyphs, ruins, historic buildings,
and artifacts; and shall leave in place any hidden cultural values
uncovered through authorized operations.

 t. This permit may be terminated upon breach of any of the conditions
herein or at the discretion of the Park Manager or authorized
representative.

 u. Permittee is required to furnish the name and contact phone number
of a designated point of contact for the event. This point of contact
shall be available at the furnished phone number at all times during the
event, and during event set-up and take-down.

-   Additional restrictions or permit conditions are attached.

**COMMENTS:**
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Permittee Initial:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**