Form 5510-1 Free Use Application and Permit Vegetative or Mineral Ma

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Form 5510-1
(April 2004)

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FORM APPROVED
OMB NO. 1004-0001
Expires: January 31, 2007

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Permit Number

FREE USE APPLICATION AND PERMIT
VEGETATIVE OR MINERAL MATERIAL

Expiration Date

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District

APPLICATION
Name of applicant

Address (include zip code)

Kind of material

Estimated quantity

Give legal land description
TOWNSHIP

RANGE

SUBDIVISION

SECTION

State of

County of

Materials are to be used for
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
authorized officer is to be notified upon completion of removal.

I 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.

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(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
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 shall be subject to the following special conditions:

Conservation practices must be carried out as provided by 43 CFR 5511.1-1(b),.2-3(c),
and .3-3;

The permittee shall clean up all work areas and shall remove or dispose of all refuse
resulting from the permittee's operations;

Equipment, personal property, and improvements must be removed within ninety (90)
days after expiration date 43 CFR 5511.3-5);

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).

Any use of the surface of the lands involved in this permit shall be such as not to
interfere with any mining claim subject to the provisions of Section 4 of the Act of July
23, 1955 (30 U.S.C. 613);

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 after permit expiration (Alaska only).

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(Signature of Authorized Officer)

(Date)
(Continued on Page 2)

APPLICANT

DISTRICT OFFICE

NOTICE
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) provide that you be furnished with
the following information required by this application:
AUTHORITY: 30 U.S.C. 601, 602; and 43 U.S.C. 1201
PRINCIPAL PURPOSE: BLM uses the information to maintain an inventory of vegetal and
mineral information and to adjudicate your rights to vegetal and mineral resources.
ROUTINE USES: BLM will disclose the information on this form pursuant to the regulations in
43 CFR 2.56.
EFFECT OF NOT PROVIDING THIS INFORMATION: If you do not furnish all the information
required by this form, your application may be rejected.

The Paperwork Reduction Act of 1995 requires us to inform you that:
This information is being collected to evaluate the amount and condition of vegetal and mineral
materials on public lands and will be used to maintain depletion records.
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 agencysponsored information collection unless it displays a currently valid OMB control number.

BURDEN HOURS STATEMENT
Public reporting burden for this form is estimated to average 30 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, (1004-0001), Bureau Clearance Officer
(WO-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.

BLM Form 5510-1, Page 2