Form 3809-5 Notification of Change of Operator and Assumption of Pas

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Form 3809-5
(August 2014)

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

NOTIFICATION OF CHANGE OF OPERATOR AND ASSUMPTION OF PAST LIABILITY

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FORM APPROVED
OMB No. 1004-0194
Expires: August 31, 2016

The mining law surface management regulations at 43 CFR 3809 require that obligations accrued or conditions created under an operation
remain with that operator until (1) Bureau of Land Management (BLM) accepts a satisfactory replacement financial guarantee adequate to
cover the previously accrued obligations and (2) BLM receives documentation that a transferee accepts responsibility for the transferor’s
previously accrued obligations. Therefore, the undersigned transferee hereby assumes all liabilities that may be outstanding on the plan of
operations or notice shown below, including, but not limited to, the obligation to properly reclaim and restore the land disturbed on said
plan or notice within the approved reclamation plan or notice filed with the BLM; provided that the obligation will not act to increase the
potential or cumulative liability above the face amount of the replacement bond to which this notification attaches in the amount stated
below as required from the transferee.
1. BLM Notice or Plan of Operations Number(s):
2. Date BLM Accepted Notice or Approved the Plan of Operations:

3. Change of operator on the Notice(s) or Plan(s) shown is proposed on
FROM: Current Operator (Transferor)

as follows:

(Date)

Address
Address
By
Signature

(Print Name)

Title
Surface Reclamation Bonding Amount Currently Obligated: Sum of
U.S. dollars ($

).

TO: Proposed Operator (Transferee)
Address
Address
By
Signature

(Print Name)

Title
Surface Reclamation Bond: Sum of
U.S. dollars ($

).
(TIN or SSN)

Change of Operator Approved Pending Acceptance of Satisfactory Bond:
(Field Manager)

cc:

State Office
Surety, if applicable

(Continued on page 2)

(Date)

NOTICES
THE PRIVACY ACT OF 1974 and the regulation in 43 CFR 2.48(d) require that you be furnished the following information in
connection with information required by this application.
AUTHORITY: 30 U.S.C. 22 et seq.; 43 U.S.C. 1732(b) and 1782(c); 31 U.S.C. 9301 et seq.; 43 CFR 3802 and 43 CFR 3809.
PRINCIPAL PURPOSE: Information is being used to establish financial responsibility for surface disturbance on public lands.
ROUTINE USES: BLM will only disclose the information according to the regulations at 43 CFR 2.56(d).
EFFECT OF NOT PROVIDING INFORMATION: Disclosure of the information is necessary to obtain or retain a benefit. Failure to
disclose this information may result in BLM’s rejection of your application.
THE PAPERWORK REDUCTION ACT OF 1995 requires us to inform you that:
The BLM collects this information to grant the right to conduct exploration and mining activities on public lands.
Response to this request is required to 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 8 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 (1004-0194), Bureau
Information Collection Clearance Officer (WO-630), 1849 C Street, N.W., Room 2134LM, Washington, D.C. 20240.

(Form 3809-5, page 2)