Form 3195-3 Refiners' tolling occurrence report

Form 3195-3	OMB Control No. 1004-0179
(June 2015)	Expires:

Submit Form To:

BUREAU OF LAND MANAGEMENT

AMARILLO FIELD OFFICE

ATTN: Assistant Field Manager for Operations

801 S. Fillmore, Suite 500

Amarillo, Texas 79101

Refiners’ Tolling Occurrence Report

FISCAL YEAR: ______: Submit within 14 days of entering into a tolling agreement

Volumes in million scf/yr

Company	Date Tolling Agreement Signed	Volume	Price (Per MCF)	Delivery Period

I certify that the information provided above accurately describes the recent tolling agreement with a non-refiner storage contract holder in the Federal Helium Program. I understand that this information will be treated as business sensitive by the BLM, but will be aggregated with other refiners’ data for the BLM’s purposes.

Company Name: Title:

Telephone: Printed Name of Authorized Agent:

Email: Signature: Date:

PAPERWORK REDUCTION ACT (PRA) STATEMENT: The PRA (44 U.S.C. 3501-3521) requires us to inform you that we collect this information to obtain documentation of refined helium deliveries. The BLM uses this information to monitor compliance with a statutory requirement that sellers of refined helium to federal agencies buy an equivalent amount of crude federal helium. Responses are required to obtain or retain a benefit (43 CFR 3195 and 50 U.S.C. 167d(b)(8)). In order to ensure the confidentiality of information submitted on this form, the BLM will aggregate the information obtained and disclose it publicly only in the aggregate. 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. The public reporting burden for this form is estimated to be 4 hours per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may send direct comments regarding the burden estimate or any other aspect of this form to the U.S. Department of the Interior, Bureau of Land Management (1004-0179), 1849 C Street, NW, Room 2134LM, Attention: Bureau Information Collection Clearance Officer (WO-630), Washington, DC 20240.