Form 5510-1 Free Use Application and Permit for Vegetative Material

Form 5510-1 June 2013 UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT FREE USE APPLICATION AND PERMIT VEGETATIVE MATERIAL	FORM APPROVED OMB NO. 1004-0001 Expires:
	Permit Number
	Expiration Date
	District
APPLICATION

Name of applicant	Address (include zip code)
Kind of material		Estimated quantity

Give legal land description

TOWNSHIP

RANGE

SECTION

SUBDIVISION

^{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 Bureau of Land Management (BLM) must 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.

(Date) ^{(Signature of Applicant)}

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 will 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;

Equipment, personal property, and improvements must be removed within ninety (90)

days after expiration date 43 CFR 5511.3-5);

Any use of the surface of the lands involved in this permit must not interfere with any mining claim subject to the provisions of Section 4 of the Act of July 23, 1955

(30 U.S.C. 613);

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

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).

(Date)

^{(Continued on page 2)} APPLICANT FIELD OFFICE

(Signature of BLM)

NOTICES

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: 16 U.S.C. 604 through 607a and 612; 43 U.S.C. 315d; and 43 CFR Part 5510 permit collection of the information requested by this form.

PRINCIPAL PURPOSE: BLM uses the information to maintain an inventory of vegetation information and to adjudicate your rights to remove vegetative resources under the Free Use Regulations at 43 CFR Part 5510.

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: Submission of the requested information is necessary to obtain a benefit. Failure to submit all of the requested information or to complete this form may result in delay or preclude the BLM’s acceptance of the application.

The Paperwork Reduction Act of 1995 requires us to inform you that:

The BLM collects this information to establish vegetative material, quantity, and compliance with the Free Use Regulations. Submission of the requested information is necessary to complete the permit transaction and obtain or retain a benefit.

The 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 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 Information Collection Clearance Officer (WO-630), 1849 C Street, NW, Room 2134LM, Washington, D.C. 20240.

(Form 5510-1, page 2)