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

Form 5510-1
(August 31, 2016)

FORM APPROVED OMB
NO. 1004-0001 Expires:
August 31, 2016

UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT

Permit Number

FREE USE APPLICATION AND PERMIT

Expiration Date

VEGETATIVE MATERIAL

District

APPLICATION
Name of applicant

Address (include zip code)

Kind of material

Estimated quantity

Give legal land description
TOWNSHIP

RANGE

SUBDIVISION

SECTION

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.

(Signature of Applicant)

(Date)

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;

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

Equipment, personal property, and improvements must be removed within ninety (90)
days after expiration date 43 CFR 5511.3-5);

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).

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);

(Signature of BLM)

(Date)
(Continued on page 2)

APPLICANT

FIELD OFFICE

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: 30 U.S.C. 601, 602; U.S.C 1201; and 43 U.S.C. 3620 and 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 Parts 3620 and 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 2134Mail Stop 401 LS, Washington, D.C. 20240.

(Form 5510-1, page 2)