Form OR 2812-6 OR 2812-6 Permittee Report of Road Use

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Overview

OR 2812-6 MAY 2009
OR 2812-6a MAY 2009

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Sheet 1: OR 2812-6 MAY 2009

							United States Department of the Interior
							Bureau of Land Management - Oregon State Office
							PERMITTEE REPORT OF ROAD USE
Permittee Name/Contact/Bill Address: ↓					Permit No.:↓		Serial No.:↓		Period From↓:		Period To↓:		Page 1 of _____
													(for this reporting period)
↓Permittee fills in this portion↓:										↓BLM responsible for this portion↓:
Material Hauled From:				BLM Road No.		Road Segment	Length used (Mi.)	Quantity hauled (MBF in Long Log)*		Surface Type	Alloc. or Non-Alloc. (A or Non)	Road Use Fees			Maintenance Fees			Surface Replacement Fees
T.	R.	Sec.	Permittee Project Name (optional)									Road Use Fee/MBF ($)**	Amount Due (NTE Current Def. Bal.)		Fee/ MBF/Mi. Used	Amount Due		Fee/ MBF/ Mi. Used	Amount Due
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
													$0.00			$0.00			$0.00
SUBTOTALS FROM PAGE 1													$0.00			$0.00			$0.00
SUBTOTALS FROM PAGE 2													$0.00			$0.00			$0.00
TOTAL ALL PAGES (AMOUNTS TO BE BILLED)													$0.00		$0.00		$0.00
PERMITTEE CERTIFICATION (Check one):												BLM Verification:
	I certify that this Report of Road Use (all pages) is true and that, to the best of my knowledge,											The hauling data in this Report of Road Use is verified. Bill can be prepared.
	is a complete statement of our hauling on U.S. roads during the above reporting period, or
	I certify that no hauling occurred on any U.S. roads during the above reporting period.
											Delegated BLM Official Date
Permittee Signature***					Title				Date
* To report Cull or Chip haul, enter the # of vehicles in the Quantity Hauled column and the fee per/vehicle mile into the Road Maintenance Fee/MBF Column.
**For Reciprocal ROW: fees are calculated per MBF. If permit is system fee--then it is a negotiated fee/MBF. If a unilateral permit, use state-wide RUF/MBF.
***Title 18 U.S.C. Section 1001 makes it a crime for any person to knowingly make to any department or agency of the United States any false, ficticious, or fraudulent statements of representation as to any matter within its jurisdiction.
Note: The Paperwork Reduction Act of 1995 requires us to inform you that: This information is being collected to determine road use and maintenance fees and verify other information relevant to operations under your right-of-way permit. The information is mandatory as a condition of your right-of-way permit and the regulations in 43 CFR 2812.8-1. Failure to submit this information may be grounds for suspension or termination of your permit. BLM may not sponsor, and you are not required to respond to, a collection of information that does not display a current valid OMB control number. Public reporting burden for this form is estimated to average 8 hours per response, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing this 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, Bureau Clearance Officer, WO-630 (1004-0168), 1849 C Street, N.W., Mail Stop 4011LS, Washington, D.C. 20240.

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Sheet 2: OR 2812-6a MAY 2009

				United States Department of Interior
					Bureau of Land Management - Oregon State Office
				PERMITTEE REPORT OF ROAD USE
				(CONTINUATION SHEET)
Permit No. (one permit per report unless all are "no haul":				Permit No.↓			Serial No. ↓		Period From↓:			Period To↓:			Page _____ of _____
															(for this reporting period)
↓Permittee fills in this portion↓:										↓BLM responsible for this portion↓:
Material Hauled From:				BLM Road No.		Road Segment	Length used (Mi.)	Quantity hauled (MBF in long log)*		Surface Type	Alloc. or Non-Alloc. (A or Non)	Road Use Fees			Maintenance Fees			Surface Replacement Fees
T.	R.	Sec.	Permittee Project Name (optional)									Road Use Fee/MBF ($)**	Amount Due (NTE Current Def. Bal.)		Fee/ MBF/Mi. Used	Amount Due		Fee/ MBF/ Mi. Used	Amount Due
												$0.00	$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
												$0.00		$0.00			$0.00
													$0.00		$0.00			$0.00
													$0.00		$0.00			$0.00
													$0.00		$0.00			$0.00
													$0.00		$0.00			$0.00
													$0.00		$0.00			$0.00
TOTALS THIS PAGE (BLM TRANSFER TO PAGE 1)→													$0.00		$0.00			$0.00
PERMITTEE CERTIFICATION for this continuation sheet:												BLM Verification:
		←	Initial here to indicate that certification on page one applies to this page as well.									The hauling data in this Report of Road Use is verified. Bill can be prepared.
											Delegated BLM Official Date
* To report Cull or Chip haul, enter the # of vehicles in the Quantity Hauled column and the fee per/vehicle mile into the Road Maintenance Fee/MBF Column.
**For Reciprocal ROW: fees are calculated per MBF. If permit is system fee--then it is a negotiated fee/MBF. If a unilateral permit, use state-wide RUF/MBF.