Form 3809-5 Notification of Change of Operator and Assumption of Pas

Form 3809-5
(February 2005)

UNITED STATES
DEPARTMENT OF THE INTERIOR

FORM APPROVED
OMB No. 1004-0194
Expires: January 31, 2007

BUREAU OF LAND MANAGEMENT

NOTIFICATION OF CHANGE OF OPERATOR AND ASSUMPTION OF PAST LIABILITY

The mining law surface management regulations at 43 CFR 3809 require that obligations accrued or conditions created under an operation remain with that
operator until (1) Bureau of Land Management (BLM) accepts a satisfactory replacement financial guarantee adequate to cover the previously
accrued obligations and (2) BLM receives documentation that a transferee accepts responsibility for the transferor’s previously accrued obligations.
Therefore, the undersigned transferee hereby assumes all liabilities that may be outstanding on the plan of operations or notice shown below, including,
but not limited to, the obligation to properly reclaim and restore the land disturbed on said plan or notice within the approved reclamation plan or notice
filed with the BLM; provided that the obligation will not act to increase the potential or cumulative liability above the face amount of the replacement bond to
which this notification attaches in the amount stated below as required from the transferee.
1. BLM Notice or Plan of Operations Number(s):

2. Date BLM Accepted Notice or Approved the Plan of Operations:

3. Change of operator on the Notice(s) or Plan(s) shown is proposed on

as follows:
(Date)

FROM: Current Operator (Transferor)
Address
Address
By
(Print Name)

Signature
Title
Surface Reclamation Bonding Amount Currently Obligated: Sum of
).

U.S. dollars ($
TO:

Proposed Operator (Transferee)
Address
Address
By
(Print Name)

Signature
Title
Surface Reclamation Bond: Sum of
U.S. dollars ($

).

(TIN or SSN)
Change of Operator Approved Pending Acceptance of Satisfactory Bond:

(Field Manager)

cc: State Office
Surety, if applicable
(Continued on page 2)

(Date)

NOTICES
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished the following information in connection with information
required by this application.
AUTHORITY: 30 U.S.C. 22 et seq.; 43 U.S.C. 1732[b] and 1782[c]; 31 U.S.C. 9301 et seq.; 43 CFR 3802 and 43 CFR 3809.
PRINCIPAL PURPOSE: Information is being used to establish financial responsibility for surface disturbance on public lands.
ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to receive a benefit. Failure to disclose this information
may result in BLM’s rejection of your application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to grant the right to conduct exploration and mining activities on public lands.
Response to this request is required to obtain a benefit.
BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a
currently valid OMB control number.

BURDEN HOURS STATEMENT: Public reporting burden for this form is estimated to average 8 minutes per response,
including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments
regarding the burden estimate or any other aspect of this form to U.S. Department of the Interior, Bureau of Land Management (1004-0194),
Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.
(Form 3809-5, page 2)