Form 3510-2 Phosphate or Sodium Use Permit

Form 3510-2 (May 2014)

FORM APPROVED OMB NO. 1004-0121

_{Expires: March 31, 2016}

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 oc- cupied, 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 con- nected 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 termi- nation of the permit or lease.

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

_{Dated as of the first day of , 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 (3) copies are sent to the Mining Supervisor of the Geological Survey.

_{EQUAL OPPORTUNITY CLAUSE}

During the performance of this contract, the permittee agrees as follows:

(1) The permittee must not discriminate against any em- ployee 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 em- ployment, 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 adver- tising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The permittee agrees to post in con- spicuous places, available to employees and applicants for employment, notices to be provided by the contract- ing officer setting forth the provisions of this nondis- crimination clause.

(2) The permittee must, in all solicitations or adver- tisements 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 rep- resentative 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’ represent- ative 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.

(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 ac- counts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain com- pliance 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 pro- cedures authorized in Executive Order No. 11246 of September 24, 1965, and such other sanctions may be imposed and remedies involved as provided in Ex- ecutive 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 par- agraphs (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 sub- contractor 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 non- compliance: 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 liti- gation to protect the interests of the United States.

_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: In accordance with the System of Records titled, “Land and Minerals Authorization Tracking System—Interior, LLM-32,” disclosure outside the Department of the Interior may be made: (1) To appropriate Federal agencies when concurrence or supporting information is required prior to granting or acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies or a member of the general public in response to a specific request for pertinent information, (3) To the U.S. Department of Justice or in a proceeding before a court or adjudicative body when (a) the United States, the Department of the Interior, a component of the Department, or when represented by the government, an employee of the Department is a party to litigation or anticipated litigation or has an interest in such litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to the litigation and is compatible with the purpose for which the records were compiled, (4) To an appropriate Federal, State, local, or foreign agency responsible for investigating, prosecuting, enforcing, or implementing a statute, regulation, rule, or order, where the disclosing agency becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation, (5) To a member of Congress or a Congressional staff member from the record of an individual in response to an inquiry made at the request of that individual, (6) To the Department of the Treasury to effect payment to Federal, State, and local government agencies, nongovernmental organizations, and individuals, and (7) To individuals involved in responding to a breach of Federal data. The BLM will only disclose this information in accordance with the Freedom of Information Act, the Privacy Act, and the provision in 43 CFR 2.56(c).

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., Room 2134 LM, Washington, D.C. 20240.