Form OR 2812/6 OR 2812/6 Report of Road Use

United States Department of the Interior
Bureau of Land Management

Page ___ of ___ (for this reporting period)
Oregon State Office

OR 2812-6 (February 2008), Page 1 of 2
OMB 1004-0168
Expires: February 28, 2014

REPORT OF ROAD USE

Bill to Name/Address (if different):

Permittee Name/Address/Contact:

Permit No.

Phone: ___________________

Serial No.

Contact: ______________________________
Information Required From Permittee:
Material Hauled From:
T.

R.

Sec.

BLM Road &
Segment No.

Length
used

Quantity
hauled
(MBF/
tons/CY)

Surface
Type

Allocated
or NonAllocated

BLM responsible for this portion:

Road Use Fees
Fee/
MBF**

TOTALS FOR BILLING (or totals on page ___ of ___):

Permittee Certification (check one):
[ ]
I certify that the above Report of Road Use is true and that to the best of my knowledge, a
complete statement of our hauling on BLM roads during the reporting period, OR.
[ ]

Haul Period
From: _____________
To: _______________

I certify that no hauling occurred on any BLM roads during the above reporting period.

Amount
Due*

$

Page _____ of _____

Maintenance Fees
Fee/
MBF/Mi.

Amount
Due

Surface Replacement
Fees
Fee/
Amount
MBF/Mi. Due

$

$

BLM Verification:
Hauling data is verified. Bill can be prepared.
___________________________________________
Delegated BLM Official
Date

Signature____________________________ Title __________________________ Date: ___________

Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly to make to any department or agency of the United States any false, fictitious, or
fraudulent statements of representation as to any matter within its jurisdiction.
Instructions: One report shall be filed for each permit used during the hauling period being reported.
*Road Use Fees billed should never exceed the deficient balance existing prior to this reporting period.
**A calculated road use fee is per MBF. If road use fees aren’t calculated, the fee in the OR/WA state-wide fee schedule is used and is calculated per MBF/mile.

OR-2812-6 (April 2005), Page 2 of 2
Report of Road Use (Continuation Sheet)

Permit No.

Serial No.

Information Required From Permittee:

Material Hauled From:
T.

R.

Sec.

BLM Road &
Segment No.

Length
used

Period From:
Quantity
hauled
(MBF/
tons/CY)

TOTALS FOR BILLING (or totals on page ___ of ___ ):

Surf. Type

Alloc or
NonAlloc

Period To:

Page ___ of ___
(for this reporting period).
BLM responsible for this portion:

Road Use Fees
Fee/
MBF**

Amount
Due*

$

Maintenance Fees
Fee/
MBF/Mi.

Amount
Due

$

Surface Replacement
Fees
Fee/
Amount
MBF/Mi. Due

$

NOTICE
The Paperwork Reduction Act of 1995 requires us to inform you that: This information is being collected to determine road use and maintenance fees and verify other information relevant to
operations under your right-of-way permit. The information is mandatory as a condition of your right-of-way permit and the regulation in 43 CFR 2812.8-1. Failure to submit this information may be
grounds for suspension or termination of your permit. BLM may not sponsor, and you are not required to respond to, a collection of information that does not display a current valid OMB control
number. Public reporting burden for this form is estimated to average 8 hours per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing
this 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, Bureau Clearance Officer, WO-630
(1004-0168), 1849 C Street, N.W., Room 2134LM Washington, D.C. 20240. The Privacy Act and 43 CFR 2.48(d) require us to furnish the following information in conection with the information
requested by this form: Authority: Section 502 of FLPMA ( 43U.S.C. 1762); Act of August 28, 1937 (43U.S.C. 1181a and 1181b); and 43 CFR Subpart 2812. PRICIPAL PURPOSE: To determine road
use and maintenance fees and verify other information relevant to operations under your right-of-way permit. ROUTINE USES: BLM will disclose the information in accordance with regulations at
43 CFR 2.56(d).