Form 3510-2 Phosphate or Sodium Use Permit

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FORM APPROVED
OMB NO. 1004-0121
Expires: February 28, 2013

Form 3510-2
(March 2010)

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
PHOSPHATE OR SODIUM USE PERMIT

Serial Number
Phosphate – act of February 25, 1920
(41 Stat. 441; 30 U.S.C. 214)
Sodium – act of February 25, 1920
(41 Stat. 447; 30 U.S.C. 263)

The Bureau of Land Management (BLM), pursuant to the above-cited act, hereby grants to:

the holder of a
permit
lease bearing the above Serial Number, the right so long as needed, used, and occupied, during the life of the permit or lease, the use of the surface of the following-described land:

for a campsite, refining works, and other purposes connected with and necessary to the proper development
and use of the deposits covered by the permit or lease
consistent with the terms of the permit or lease. All
rights hereunder to cease and terminate upon the termination of the permit or lease.
Dated as of the first day of

The annual charge for this permit is $
an
acre, or fraction thereof, for the area covered hereby payable on or before the anniversary date of
this permit.

, 20

(Name - Print)

(Signature of BLM)

(Title)

Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 make it a crime for any person knowingly and willfully to make to any
department or agency of the United States any false, fictitous, or fraudulent statements or representations as to any matter within its jurisdiction.
(See Instructions and Equal Opportunity Clause on page 2)

INSTRUCTIONS

Prepare original and four (4) copies. Submit all copies
to BLM for signature on original and first copy. Original is
assembled with the case record; first copy is

sent to the lessee or permittee; and three
copies are sent to the Mining Supervisor of
Geological Survey.

(3)
the

EQUAL OPPORTUNITY CLAUSE
During the performance of this contract, the permittee
agrees as follows:
(1) The permittee must not discriminate against any employee or applicant for employment because of race,
creed, color, sex, or national origin. The permittee must
take affirmative action to ensure that applicants are
employed, and that employees are treated during employment, without regard to their race, creed, color,
sex, or national origin. Such action must include, but
not be limited to the following: employment, upgrading,
demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms
of compensation; and selection for training, including
apprenticeship. The permittee agrees to post in conspicuous places, available to employees and applicants
for employment, notices to be provided by the contracting officer setting forth the provisions of this nondiscrimination clause.
(2) The permittee must, in all solicitations or advertisements for employees placed by or on behalf of the
permittee, state that all qualified applicants must receive
consideration for employment without regard to race,
creed, color, sex, or national origin.
(3) The permittee must send to each labor union or representative of workers with which he has a collective
bargaining agreement or other contract or understanding,
a notice, to be provided by the agency contracting
officer, advising the labor union or workers’ representative of the permittee’s commitments under Section 202
of Executive Order No. 11246 of September 24, 1965,
and must post copies of the notice in conspicuous
places available to employees and applicants for
employement.
(4) The permittee must comply with all provisions of
Executive Order No. 11246 of September 24, 1965, and
of the rules, regulations, and relevant orders of the
Secretary of Labor.

(Continued on page 3)

(5) The permittee must furnish all information and
reports required by Executive Order No. 11246 of
September 24, 1965, and by the rules, regulations, and
orders of the Secretary of Labor, or pursuant thereto,
and must permit access to his books, records, and accounts by the contracting agency and the Secretary of
Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders.
(6) In the event of the permittee’s noncompliance with
the nondiscrimination clauses of this contract or with
any of such rules, regulations, or orders, this contract
may be cancelled, terminated or suspended in whole or
in part and the permittee may be declared ineligible for
further Government contracts in accordance with procedures authorized in Executive Order No. 11246 of
September 24, 1965, and such other sanctions may be
imposed and remedies involved as provided in Executive Order No. 11246 of September 24, 1965, or by
rule, regulation, or order of the Secretary of Labor, or
as otherwise provided by law.
(7) The permittee must include the provisions of paragraphs (1) through (7) in every subcontract or purchase
order unless exempted by rules, regulations, or orders
of the Secretary of Labor issued pursuant to Section 204
of Executive Order No. 11246 of September 24, 1965,
so that such provisions will be binding upon each subcontractor or vendor.
The permittee must take such
action with respect to any subcontract or purchase order
as the contracting agency may direct as a means of
enforcing such provisions including sanctions for noncompliance: Provided, however, That in the event the
permittee becomes involved in, or is threatened with,
litigation with a subcontractor or vendor as a result of
such direction by the contracting agency, the permittee
may request the United States to enter into such litigation to protect the interests of the United States.

(Form 3510-2, page 2)

NOTICES
The Privacy Act of 1974 and the regulation, in 43 CFR 2.48(d) provide that you be furnished with the following information
required by this application.
AUTHORITY: 30 U.S.C. 181 et seq, 43 U.S.C. 3500
PRINCIPAL PURPOSE: BLM will use the information you provide to determine whether or not to issue you a use permit for
your phosphate or sodium lease and, if you qualify, will issue you the permit on this form.
ROUTINE USES: BLM will disclose information to: (1) appropriate Federal, State, local or foreign agencies, when relevant to
civil, criminal, or regulatory investigations or prosecutions; (2) appropriate Federal agencies when their concurrence is required
before BLM grants a right in public lands or resources: (3) a member of the public in response to a specific request for
Pertinent information; (4) a congressional office in response to an inquiry made at the request of an individual; and (5) to a
consumer reporting agency to expedite collecting debts owed the government.
EFFECT OF NOT PROVIDING INFORMATION: Filing of this information is required to obtain and keep a benefit. If you
do not provide the information, BLM may not issue a use permit to you.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations at 43 CFR 3500, which implement the provisions of the Mineral
Leasing Act of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section 402 of Reorganization Plan
No. 3 1946.
BLM uses this information to determine whether or not you qualify for a use permit for your sodium or phosphate lease.
Response to this request is required to obtain and keep 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 10 hours 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 (1004-0121), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Mail Stop
401LS, Washington, D.C. 20240.

(Form 3510-2, page 3)