Form FWS Form 3-2469 FWS Form 3-2469 Oil and Gas Operations Special Use Permit Application

OMB Control Number 1018-0162 Expiration Date: XX/XX/20XX

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Refuge Name: ___________________________________

Address: _______________________________________

_______________________________________

Attn: (Refuge Official) ___________________________________________

Email: __________________________________________

Phone #: ________________________________________

INSTRUCTIONS FOR COMPLETING APPLICATION

You may complete the application portion in person at the refuge office, verbally, or electronically and submit it to the refuge for review. If you have a question, contact the specific refuge headquarters office where you propose to conduct the activity to determine applicability of a particular item and how to comply with a particular information request. We may add special conditions or permit stipulations to permit prior to approval. Information for Part 1 (contact information) is required. Complete the other Parts of the form as they apply to your proposed activity as explained below.

You do not need to resubmit information that is already on file with the Service, provided that such information is still current and accurate. You should reference this information in your oil and gas operations permit application.

You may submit documents and materials submitted to other Federal and State agencies noting how the information meets the specific requirements of the Operations Permit.

Type of Permit (identify the type of permit you are applying for (check all that apply):

 Temporary Access Permit - complete Parts 1 and 2.

 Operations Permit: all applicants must complete Parts 1, 3, 4, 8, 9, and 10. In addition, if you are proposing:

Geophysical exploration - complete Part 5.

Drilling operations- complete Part 6

Production operations - complete Part 7

After you complete the application, sign the application and return it to the refuge.

SIGNATURES

Sign, date, and print this form and return it to the refuge for processing.

Signature of Applicant: _______________________________________Date of Application:_________________________________

PART 1: CONTACT INFORMATION

1) Name of Applicant: ______________________________________ 2) Title: _________________________________________

3) Business Name: ___________________________________________________________________________________________

4) Street Address: ____________________________________________________________________________________________

5) City/State/Zip:_____________________________________________________________________________________________­­_

6) Business Phone #: ________________ 7) Business Fax #: ____­____________ 8) Email ________________________________

9) Provide the name of the operator, employee, agent, or contractor responsible for overall management of the proposed operations.

Representative: _________________________________________________________________________________________

10) Business Name: _________________________________________________________________________________________

11) Street Address: ___________________________________________________________________________________________

12) City/State/Zip: ____________________________________________________________________________________________

13) Business Phone #: __________________ 14) Business Fax #: _______________ 15) Email: ____________________________

16) Required Documents

• Documentation demonstrating the right to operate within the refuge.

Attached?  Yes  No  Previously Provided: _________________________________________________________

PART 2: TEMPORARY ACCESS FOR RECONNAISSANCE SURVEYS

(Provide information for items 17 through 20 on separate sheets and identify each response by number. For item 21, indicate below whether or not required document is attached. If the document was previously provided, indicate date and other specifics.)

17) List names, addresses, phone numbers and job title/qualifications of all specialists responsible for conducting the reconnaissance surveys (Only required if the assistants/subcontractors/subpermittees will be operating on the refuge without the permittee being present.)

18) Briefly describe the intended operation so that we can determine reconnaissance survey needs.

19) Describe the survey methods you intend to use to identify the natural and cultural resources.

20) Describe proposed means of access and routes proposed for conducting the reconnaissance surveys.

21) Required Documents

• Location map (to-scale and determined by us as acceptable) delineating the proposed reconnaissance survey area in relation to the refuge boundary and the proposed area of operations attached?

Attached?  Yes  No  Previously Provided: _________________________________________________________

PART 3: EXISTING CONDITIONS FOR YOUR AREA OF OPERATIONS

(All applicants applying for an operations permit must complete this part. Provide information for items 22 through 25 on separate sheets and identify each response by number.)

22) Describe the natural features including streams, lakes, ponds, wetlands, topographic relief, and areas the Service has indicated to you are sensitive.

23) Describe the locations of existing roads, trails, railroad tracks, pipeline right-of-ways, pads, and other disturbed areas.

24) Describe the locations of existing structures that your operations could affect, including buildings, pipelines, producing oil and gas wells, freshwater wells, underground and overhead electrical lines, and other utility lines.

25) Describe the natural resource and cultural resource survey reports for your proposed area of operations.

PART 4: PROPOSED NEW SURFACE USES

(All applicants applying for an operations permit must complete this part. Provide information for items 26 through 32 on separate sheets and identify each response by number. For item 33, indicate below whether or not required documents are attached. If a document was previously provided, indicate date and other specifics.)

26) Describe and show the method and diagrams, including cross-sections, of any proposed pad construction, road construction, cut-and-fill areas, erosion control, and surface maintenance.

27) Describe the number and types of equipment and vehicles, including an estimate of vehicular round trips associated with each phase of operation.

28) Describe the estimated timetable for each phase of the proposed operations, including any operational timing constraints.

29) Describe the type and extent of security measures proposed at your area of operation.

30) Describe the power sources and their transmission systems for the proposed operations.

31) Describe the types and quantities of all solid and liquid waste generated and the proposed methods of storage, handling, and disposal.

32) Describe the source, quantity, access route, and transportation/conveyance method for all water to be used in operations; and estimations of any anticipated waste water volumes generated and how they will be managed and disposed of.

33) Required Documents:

• Location map (to-scale and determined by us as acceptable) identifying the proposed area of operations, existing conditions (as described in Part 3), and proposed new surface uses that clearly identifies the boundaries of each of your mineral tract(s) in relation to your proposed operations and the relevant refuge boundary.

Attached?  Yes  No  Previously Provided: _________________________________________________________

• Location map (to-scale and determined by us as acceptable) showing proposed access routes of new surface disturbances as determined by a location survey.

Attached?  Yes  No  Previously Provided: _________________________________________________________

• Location map (to-scale and determined by us as acceptable) showing the proposed location of all support facilities, including those for transportation (e.g., vehicle parking areas, helicopter pads), sanitation, occupation, staging areas, fuel storage areas, refueling areas, loading docks, water supplies, and disposal facilities).

Attached?  Yes  No  Previously Provided: _________________________________________________________

PART 5: GEOPHYSICAL EXPLORATION

(Only applicants proposing to conduct geophysical exploration must complete this part. Provide information for items 34 through 37 on separate sheets and identify each response by number. For item 38, indicate below whether or not required document is attached. If the document was previously provided, indicate date and other specifics.)

34) Describe the number of crews and numbers of workers in each crew.

35) Describe the acquisition methods, including the procedures, specific equipment you will use, and energy sources (e.g., explosives, vibroseis trucks).

36) Describe methods of access along each survey line for personnel, materials, and equipment.

37) List of all explosives, blasting equipment, chemicals, and fuels you will use in the proposed operations, including a description of proposed disposal methods, transportation methods, safety measures, and storage facilities.

38) Required Documents:

• Map (to-scale and determined by us to be acceptable) showing the positions of each survey line including all source and receiver locations as determined by a locational survey, and including shot point offset distances from wells, buildings, other infrastructure, cultural resources, and environmentally sensitive areas.

Attached?  Yes  No  Previously Provided: _________________________________________________________

PART 6: DRILLING OPERATIONS

(Only applicants proposing to conduct drilling operations must complete this part. Provide information for items 39 through 42 on separate sheets and identify each response by number.)

39) Describe the well pad construction, including dimensions and cross sections of: cut-and-fill areas and excavations for ditches, sumps, and spill control equipment or structures, including lined areas.

40) Describe the drill rig and equipment layout, including rig components, fuel tanks, testing equipment, support facilities, storage areas, and all other well-site equipment and facilities.

41) Describe the type and characteristics of the proposed drilling mud systems.

42) List the equipment, materials, and methods of surface operations associated with your drilling, well casing and cementing, well control, well evaluation and testing, well completion, well stimulation, and well plugging programs.

PART 7: PRODUCTION OPERATIONS

(Only Applicants proposing to conduct production operations must complete this part. Provide information for items 43 through 47 on separate sheets and identify each response by number. For item 48, indicate below whether or not required documents are attached. If a document was previously provided, indicate date and other specifics.)

43) Provide the dimensions and the to-scale layout of the well pad, clearly identifying well locations, noting partial reclamation areas; gathering, separation, metering, and storage equipment; electrical lines; fences; spill control equipment or structures including lined areas, artificial lift equipment, tank batteries, treating and separating vessels, secondary or enhanced recovery facilities, water disposal facilities, gas compression and/or injection facilities; metering points; sales point (if on lease); tanker pickup points; gas compressor, including size and type (if applicable); and any other well site equipment.

44) Provide a general description of anticipated stimulations, servicing, and workovers.

45) Describe the procedures and equipment used to maintain well control.

46) Describe the method and means used to transport produced oil and gas, including vehicular transport; flowline and gathering line construction and operation, pipe size, and operating pressure; cathodic protection methods; surface equipment use; surface equipment location; maintenance procedures; maintenance schedules; pressure detection methods; and shutdown procedures.

47) Describe the equipment, materials, and procedures proposed for well plugging.

48) Required Documents:

• Road and well pad maintenance plan, including equipment and materials to maintain the road surface and control erosion.

Attached?  Yes  No  Previously Provided: ________________________________________________________

• Vegetation management plan on well sites, roads, pipeline corridors, and other disturbed surface areas, including control of noxious or invasive species.

Attached?  Yes  No  Previously Provided: ________________________________________________________

• Stormwater management plan for the well site

Attached?  Yes  No  Previously Provided: _________________________________________________________

• Produced water storage and disposal plan.

Attached?  Yes  No  Previously Provided: ________________________________________________________

PART 8: MITIGATION ACTIONS AND ALTERNATIVES CONSIDERED

(All applicants applying for an operations permit must complete this part. Provide information for items 49 through 51 on separate sheets and identify each response by number.)

49) Describe the steps you propose to take to mitigate anticipated adverse environmental impacts on refuge resources and uses, including but not limited to, the refuge’s land features, land uses, fish and wildlife, vegetation, soils, surface and subsurface water resources, air quality, noise, lightscapes, viewsheds, cultural resources, and economic environment.

50) Describe any anticipated impacts that you cannot mitigate.

51) List alternatives considered that met the criteria of technologically feasible, least damaging methods of operations, as well as the costs and environmental effects of those alternatives.

PART 9: SPILL CONTROL AND EMERGENCY PREPAREDNESS PLAN

(All applicants applying for an operations permit must complete this part. If you have a spill prevention control and countermeasure (SPCC) plan prepared under 40 CFR Part 112 that includes all the information required by this section, you may attach that plan to this application. Provide information for items 59 through 70 on separate sheets and identify each response by number.)

52) Spill, Fire, or Accident Company Representative: ________________________________________________________________

53) Business Name: _________________________________________________________________________________________

54) Street Address: ___________________________________________________________________________________________

55) City/State/Zip: ___________________________________________________________________________________________

56) Emergency Contact Phone #: _________________ 57) Business Fax #: _____________ 58) Email: ___________________________

59) Describe the notification procedures and steps taken to minimize damage in event of spill, fire, or accident.

60) Identify contaminating or toxic substances used within your area of operations or expected to be encountered during operations.

61) Provide a trajectory analysis for for potential spills not contained on location.

62) Identify abnormal pressure, temperature, toxic gases or substances, or other hazardous conditions at your area of operations or expected to be encountered during operations.

63) Describe your measures (e.g., procedures, facility design, equipment, etc.) to minimize risks to human health, safety, and the environment.

64) Describe the steps to prevent accumulations of oil or other materials deemed to be fire hazards from occurring in the vicinity of well locations and lease tanks.

65) Describe the equipment and methods for containment and cleanup of contaminating substances, including a description of the equipment available at your area of operations and equipment available from local contractors.

66) Provide the storm water drainage plan and actions intended to mitigate stormwater runoff.

67) Provide the material safety data sheets for each material you will use/encounter during operations, including expected quantities maintained at your area of operations.

68) Describe the emergency actions you will take in the event of injury or death to fish and wildlife or vegetation.

69) Describe emergency actions you will take in the event of accidents causing human injury.

70) Provide the contingency plans for conditions and emergencies other than spills, such as if your area of operations is located in areas prone to hurricanes, flooding, tornados, fires, or earthquakes.

PART 10: RECLAMATION

(All applicants applying for an operations permit must complete this part. Provide information for items 71 and 72 on separate sheets and identify each response by number.)

71) List the specific equipment, materials, methods, and schedule used to meet the operating standards for reclamation.

72) Provide an itemized list of the estimated costs that a third party would charge to complete reclamation.

Notice

In accordance with the Privacy Act (5 U.S.C. 552a) and the Paperwork Reduction Act (44 U.S.C. 3501), please note the following information:

The issuance of a permit and collection of fees on lands of the National Wildlife Refuge System are authorized by the National Wildlife Refuge System Administration Act (16 U.S.C. 668dd-ee) as amended, and the Refuge Recreation Act (16 U.S.C. 460k-460k-4).

The information that you provide is required to obtain or retain a benefit. We use the requested information to evaluate the qualifications, determine eligibility, and document permit applicants under the above Acts. It is our policy not to use your name for any other purpose. We maintain the information in accordance with the Privacy Act. We will consider all information you provide in reviewing this application. False, fictitious, or fraudulent statements or representations made in the application may be grounds for revocation of the Special Use Permit and may be punishable by fine or imprisonment (18 U.S.C. 1001). Failure to provide all required information is sufficient cause for the U.S. Fish and Wildlife Service to deny a permit.

We also may make routine use disclosures: (a) to the U.S. Department of Justice when related to litigation or anticipated litigation; (b) of information indicating a violation or potential violation of a statute, rule, order, or license to appropriate Federal, State, local, or foreign agencies responsible for investigating or prosecuting the violation or for enforcing or implementing the statute, rule, regulations, order, or license; (c) from the record of the individual in response to an inquiry from a Congressional office made at the request of the individual (42 FR 19083; April 11,1977); and (d) to provide addresses obtained from the Internal Revenue Service to debt collection agencies for purposes of locating a debtor to collect or compromise a Federal Claim against the debtor, or to consumer reporting agencies to prepare a commercial credit report for use by the Department of Justice (48 FR 54716; December 6, 1983).

An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this information collection and assigned control number 1018-0162. The public reporting burden for this information collection varies based on the requested use. We estimate the relevant public reporting burden for the application for Temporary Access to average 17 hours per response. We estimate the time to complete an application for an Operations Permit will average 140 hours per response. These estimates include time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. You may send comments on this form or any aspect of this information collection to the Information Collection Clearance Officer, U.S. Fish and Wildlife Service, 5275 Leesburg Pike, MS: BPHC, Falls Church, Virginia, 22041.

PERMIT CONDITIONS

The following terms will be a part of your permit.

General Terms and Conditions

1. You must comply with all operating standards in §§ 29.111 through 29.117, as well as with the standards in §§ 29.118 and 29.119, if applicable. These operating standards will be incorporated into the terms and conditions of your operations permit. Violation of these operating standards unless approved in your operations permit will subject you to the Prohibited Acts and Penalties provisions of §§ 29.190 through 29.192.

2. You are responsible for ensuring that all of your contractors and subcontractors comply fully with the requirements of this subpart.

3. You may be required to reimburse the Service for the costs of processing and administering temporary access permits and operations permits.

4. You may not use any surface water or groundwater from a source located on a refuge unless you have demonstrated a right to use that water or the use has been approved by the Service.

5. You must provide the refuge an affidavit, signed by an official who is authorized to legally bind the company, stating that proposed operations are in compliance with all applicable Federal, State, and local laws and regulations and that all information submitted to the Service is true and correct.

6. You agree to indemnify and hold harmless the United States and its officers and employees from and against any and all liability of any kind whatsoever arising out of or resulting from the acts or omissions of you and your employees, agents, representatives, contractors, and subcontractors in the conduct of activities under the operations permit.

7. You will be required to take all reasonable precautions to avoid, minimize, rectify, or reduce the overall impacts of your proposed oil and gas activities to the refuge.  You may be required to mitigate for surface impacts and lost uses by providing for habitat creation, habitat restoration, land purchase, or other compensation agreed to by the Service.

8. You will be responsible for unanticipated and unauthorized damages as a direct or indirect result of your operations.  You will be responsible for the actions and consequences of your employees and subcontractors.  You will also be responsible for any reclamation of damages to refuge resources caused by your operations as a result of severe weather, fire, earthquakes, or the like thereof.

Other General Conditions and Requirements

1) Responsibility of Permittee: The permittee, by operating on the premises, shall be considered to have accepted these premises with all facilities, fixtures, or improvements in their existing condition as of the date of this permit. At the end of the period specified or upon earlier termination, the permittee shall give up the premises in as good order and condition as when received except for reasonable wear, tear, or damage occurring without fault or negligence. The permittee will fully repay the Service for any and all damage directly or indirectly resulting from negligence or failure on his/her part, and/or the part of anyone of his/her associates, to use reasonable care.

2) Operating Rules and Laws: The permittee shall keep the premises in a neat and orderly condition at all times, and shall comply with all municipal, county, and State laws applicable to the operations under the permit as well as all Federal laws, rules, and regulations governing national wildlife refuges and the area described in this permit. The permittee shall comply with all instructions applicable to this permit issued by the refuge official in charge. The permittee shall take all reasonable precautions to prevent the escape of fires and to suppress fires and shall render all reasonable assistance in the suppression of refuge fires.

3) Use Limitations: The permittee’s use of the described premises is limited to the purposes herein specified and does not, unless provided for in this permit, allow him/her to restrict other authorized entry onto his/her area; and allows the U.S. Fish and Wildlife Service to carry on whatever activities are necessary for: (1) protection and maintenance of the premises and adjacent lands administered by the U.S. Fish and Wildlife Service; and (2) the management of wildlife and fish using the premises and other U.S. Fish and Wildlife Service lands.

4) Transfer of Privileges: This permit is not transferable, and no privileges herein mentioned may be sublet or made available to any person or interest not mentioned in this permit. No interest hereunder may accrue through lien or be transferred to a third party without the approval of the U.S. Fish and Wildlife Service and the permit shall not be used for speculative purposes.

5) Compliance: The U.S. Fish and Wildlife Service’s failure to require strict compliance with any of this permit’s terms, conditions, and requirements shall not constitute a waiver or be considered as a giving up of the U.S. Fish and Wildlife Service’s right to thereafter enforce any of the permit’s terms or conditions.

6) Conditions of Permit not Fulfilled: If the permittee fails to fulfill any of the conditions and requirements set forth herein, the U.S. Fish and Wildlife Service shall retain all money posted under this permit to be used to satisfy as much of the permittee’s obligation as possible.

7) Permit Payments: All payment shall be made on or before the due date to the local representative of the U.S. Fish and Wildlife Service by a postal money order or check made payable to the U.S. Fish and Wildlife Service.

8) Termination Policy: At the termination of this permit the permittee shall immediately give up possession to the U.S. Fish and Wildlife Service representative, reserving, however, the rights specified in paragraph 11 below. If he/she fails to do so, he/she will pay the U.S. Fish and Wildlife Service, as liquidated damages, an amount double the rate specified in this permit for the entire time possession is withheld. Upon yielding possession, the permittee will still be allowed to reenter as needed to remove his/her property as stated in paragraph 11 below. The acceptance of any fee for the liquidated damages or any other act of administration relating to the continued tenancy is not to be considered as an affirmation of the permittee’s action nor shall it operate as a waiver of the U.S. Fish and Wildlife Service’s right to terminate or cancel the permit for the breach of any specified condition or requirement.

9) Revocation Policy: The U.S. Fish and Wildlife Service may revoke this permit without notice for noncompliance with the terms hereof, or for violation of general and/or specific laws or regulations governing national wildlife refuges or other applicable laws, namely the Endangered Species Act.

10) Damages: The U.S. Fish and Wildlife Service shall not be responsible for: any loss or damage to property including but not limited to crops, animals, and machinery; injury to the permittee or his/her relatives or to the officers, agents, employees, or any other(s) who are instructed to be on the premises; the sufferance from wildlife or employees or representatives of the U.S. Fish and Wildlife Service carrying out their official responsibilities. The permittee agrees to hold the U.S. Fish and Wildlife Service harmless from any and all claims for damages or losses that may arise to be incident to the flooding of the premises resulting from any associated government river and harbor, flood control, reclamation, or Tennessee Valley Authority activity.

11) Removal of Permittee’s Property: Upon the expiration or termination of this permit, if all rental charges and/or damage claims due to the U.S. Fish and Wildlife Service have been paid, the permittee may, within a reasonable period as stated in the permit or as determined by the U.S. Fish and Wildlife Service official in charge, but not to exceed 60 days, remove all structures, machinery, and/or equipment, etc., from the premises for which he/she is responsible. Within this period the permittee also must remove any other of his/her property. Upon failure to remove any of the above items within the aforesaid period, they shall become the property of the U.S. Fish and Wildlife Service.

This application form is not valid as a permit

but may be used as a reference document attached to the official permit.

Only official refuge personnel may assign a valid permit number and permit term to this application form

after the permit has been approved.

FWS Form 3-2469

XX/14