Form 3195-3 Refiners' Tolling Occurrence Report

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Form 3195-3
(April 2016)

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OMB Control No.:  1004-0179
Expires: 11/30/2018

BUREAU OF LAND MANAGEMENT
AMARILLO FIELD OFFICE
ATTN: Assistant Field Manager for Operations
801 S. Fillmore, Suite 500
Amarillo, Texas 79101
Refiners’ Tolling Occurrence Report

FISCAL YEAR:

: Submit within 14 days of entering into a tolling agreement

Volumes in million scf/yr
Company

Date Tolling
Agreement
Signed

Volume

Price
(Per MCF)

Delivery Period

I certify that the information provided above accurately describes the recent tolling agreement with a non-refiner storage contract holder in
the Federal Helium Program. I understand that this information will be treated as business sensitive by the BLM, but will be aggregated with
other refiners’ data for the BLM’s purposes.

Company Name:
Telephone:
Email:

Title:
Printed Name of Authorized Agent:
Signature:

Date:

PAPERWORK REDUCTION ACT (PRA) STATEMENT: The PRA (44 U.S.C. 3501-3521) requires us to inform you that we collect this
information to obtain documentation of refined helium deliveries. The BLM uses this information to monitor compliance with a statutory
requirement that sellers of refined helium to federal agencies buy an equivalent amount of crude federal helium. Responses are required to
obtain or retain a benefit (43 CFR 3195 and 50 U.S.C. 167d(b)(8)). In order to ensure the confidentiality of information submitted on this
form, the BLM will aggregate the information obtained and disclose it publicly only in the aggregate. 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. The public reporting
burden for this form is estimated to be 4 hours per response, including the time for reviewing instructions, gathering and maintaining data,
and completing and reviewing the form. You may send direct comments regarding the burden estimate or any other aspect of this form to
the U.S. Department of the Interior, Bureau of Land Management (1004-0179), 1849 C Street, NW, Room 2134LM, Attention: Bureau
Information Collection Clearance Officer (WO-630), Washington, DC 20240.
Form 3195-3