3604-1b Mineral Material Free Use Permit

Form 3604-1b
(August 2016)

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

UNITED STATES
DEPARTMENT OF THE INTERIOR
MINERAL MATERIAL
FREE USE PERMIT

BUREAU OF LAND
MANAGEMENT
Expiration Date

Permit (Case) Serial Number
Permittee Name and Address:
Legal land description of authorized permit area:
Township

Meridian

Section

Range

Subdivision

Acres

This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. 2 and 1201. Free use permits are issued subject to the
requirements of 43 CFR Part 3600 now or hereafter in force.
This permit is hereby issued for the materials applied for but may be canceled if it appears that this this permit was issued erroneously or the
terms or conditions contained herein are not observed.
The permit is subject to the following standard stipulations:
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. 612);
The permittee must allow BLM access for inspections as required by 43 CFR 3601.51
The permittee must clean up all work areas and must remove or dispose of all refuse resulting from the permittee’s operations,
and equipment, personal property, and improvements must be removed within ninety (90) days after the permit expiration date
as required by 43 CFR 3601.52
An annual report indicating the amount (cubic yards or tons) of material removed must be filed with the BLM Field Office on the
anniversary date of the permit, and within thirty (30) days after permit expiration.
The permit is also subject to the following SPECIAL CONDITIONS:
Authorized purpose:
Authorized quantity, in-place

Authorized term
years

months

days

cubic yards or

tons

Check all that apply:
Permittee Mining and Reclamation plan is required per 43 CFR 3601.40-44
Permittee is responsible for reclamation of permit area
Financial Guarantee is required per 43 CFR 3602.14
Removal area is within Community Pit – Common Use Area - Serial No.
Permittee will perform reclamation in Community Pit – Common Use Area in lieu of reclamation fee
Permittee must follow/comply with BLM mining and reclamation plan
Permittee will pay a reclamation fee for Community Pit – Common Use Area as identified below:
Quantity
Type of Material

(select applicable in-place units)
cu. yds.

tons

Reclamation Fee
(select applicable in-place units)
$ per cu. yds.

$ per ton

TOTAL Reclamation
Fee
($)

BLM will check this box if there are additional stipulations attached to this permit.
(Continued on page 2)

(Form 3604-1b, page 1)

I HEREBY AGREE TO COMPLY WITH the regulations at 43 CFR Part 3600 and the stipulations and special conditions as set forth in this permit.
I CERTIFY that the: (a) materials to be removed will be used for the authorized purpose noted above; (b) none of the materials removed will be
sold or bartered; (c) removal of materials will begin only upon receipt of an approved copy of this permit and will cease upon the expiration date
or removal of the authorized quantity, whichever comes first; and, (d) the Bureau of Land Management (BLM) will be notified upon completion
of removal.

(Signature of Applicant)

(Printed Name)

(Title)

(Date)

THE UNITED STATES OF AMERICA
By

(Signature)

(Printed Name)

(Title)

(Date)

(BLM office)

The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate the amount and condition of mineral materials on public lands and it will be used to maintain depletion
records.
The BLM is collecting this information to process your application and effect a binding permit.
The BLM will use this information to identify and communicate with applicants.
Response to this request is required to obtain 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: The combined public reporting burden for Forms 3604-1a and 3604-1b is estimated to average 45 minutes to complete
both forms, 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, N.W., Mail Stop 2134LM, Washington, D.C. 20240.

(Form 3604-1b, page 2)