Form BLM-NEW Equipment Application

OMB Control No.: 1004-0210

Expiration Date: XX/XX/20XX

General Information	Select Type of Equipment
01A. Date of Application
Test Specimen Information
02A. Product Name
03A. Manufacturer Company Name
04A. Manufacturer Contact Name
05A. Address (Street)
06A. Address (Line 2)
07A. City, State, Zip Code
08A. Phone Number
09A. Email
Applicant (If Other Then Manufacturer)
10A. Company Name
11A. Contact Name
12A. Address (Street)
13A. Address (Line 2)
14A. City, State, Zip Code
15A. Phone Number
16A. Email
<Either 17A or 18A must be Attached>
17A. Manufacturer Letter	Yes / No
18A. Notarized Affidavit From Applicant	Yes / No
19A. Has Product Previously Been Evaluated	Yes / No
3rd Party Lab Information
20A. Company Name
21A. Contact Name
22A. Address (Street)
23A. Address (Line 2)
24A. City, State, Zip Code
25A. Phone Number
26A. Email
27A. Date of Test
28A. Name of Person Conducting Test
29A. Accreditation Information
30A. Expiration of Accreditation

Detailed Information On Test Specimen(s)	(Use multiple pages if needed)
01B. Make
02B. Model
03B. Size
04B. Serial Number / Date of Manufacture (Specimen 1)
05B. Serial Number / Date of Manufacture (Specimen 2)
06B. Serial Number / Date of Manufacture (Specimen 3)
07B. Serial Number / Date of Manufacture (Specimen 4)
08B. Serial Number / Date of Manufacture (Specimen 5)
09B. Design Pressure Range (With Units)
10B. Design Operating Temperature Range (With Units)
11B. Design Ambient Temperature Range (With Units)
12B. Electrical Power (If needed)

Notice to applicants:

Please direct any questions or concerns about the contents of these testing protocols to the PMT via the email [email protected]. Only questions or concerns directed to [email protected] will be considered.

Key:

01A. Date of Application – date in which the application with test data results pursuant to the applicable test protocol is submitted to BLM

02A. Product Name – the marketed name of the test specimen

03A. Manufacturer Company name – the name of the company that produces the test specimen

04A Manufacturer Contact Name – a point of contact with the manufacturing company familiar with the testing to whom BLM may direct questions

05A Address Line 1 – Street address – Business address of the Manufacturer Contact person

06A Address Line 2 – Suite number associated with the street address of the manufacturer

07A City, State, Zip Code – Associated with the manufacturer’s business address

08A Phone number – Phone number of the Manufacturer Contact person named in 04A

09A Email – Email address of the Manufacturer Contact person named in 04A

10A Company name – Company name of the applicant when the applicant is other than the manufacturer of the device

11A Contact name – a point of contact of the applicant for the Company named in 10A

12A Address (Street) – Street address – Business address of the Company contact person named in 11A

13A Address Line 2 – Suite number associated with the street address of the Company named in 10A

14A City, State, Zip Code - Associated with the Company’s business address named in 10A

15A Phone number – Phone number of the Company Contact person named in 11A

16A Email – Email address of the Company Contac person named in 11A

17A Manufacturer Letter - An authorized representative of the manufacturer submits a letter to the PMT 

• confirming they manufacture the device and supply it to the entity marketing the device; 

• provides concurrence that the marketing company is licensed to market their device under a different name and model number; and 

• includes the specific model number(s) and size(s) of devices they supply to the marketing company 

18A Notarized Affidavit from Applicant – An authorized representative of the marketing company submits a notarized affidavit to the PMT

• listing all changes they make to the device;  

• certifying that they receive the device from the manufacturer and rebrand the device without making any changes that would affect the performance of the device; and 

• providing a cross reference between the model number provided by the manufacturer with the model number placed on the device by the marketing company, if applicable.  

19A Has Product Previously Been Evaluated – If the product the application is being submitted for is marketed under a different name and already appears on the BLM approved equipment list, indicate “Yes” here.

20A Company name – Company name of the 3^rd party laboratory conducting the test

21A Contact name – Point of contact from the company named in 20A

22A Address (Street) – Address of the company conducting the test

23A Address (Line 2) - Suite number associated with the street address of the Company named in 21A

24A City, State, Zip Code - Associated with the Company’s business address named in 20A

25A Phone number – Phone number of the Company Contact person named in 20A

26A Email – Email address of the Company Contac person named in 20A

27A Date of Test – First day of the first test conducted

28A Name of person conducting the test – Name of lab representative overseeing the test at the test facility

29A Accreditation Information – Name of accrediting body and the accreditation standard to which the 3^rd party lab is certified

30A Expiration of Accreditation – Date on which the applicable accreditation of the laboratory expires

01B Make – A style or series within the manufacturer’s product line.

02B Model – Model number must represent a unique design that does not change the critical characteristics of the test specimen

03B Size – Nominal size of test specimen, as applicable

04B / 05B / 06B / 07B / 08B Serial number / Date of Manufacture – serial number from the test specimen and the date of manufacture

09B Design Pressure Range (with Units) – Manufacturer’s published minimum allowable operating pressure and maximum allowable operating pressure, where applicable

10B Design Operating Temperature Range (with Units) - Manufacturer’s published minimum allowable operating temperature and maximum allowable operating temperature, where applicable

11B Design ambient Temperature Range (with Units) - Manufacturer’s published minimum allowable ambient temperature and maximum allowable ambient temperature, where applicable

12B Electrical Power (if needed) – description of electrical power characteristics, i.e. DC/AC, voltage, etc.

NOTICES

Paperwork Reduction Act Statement: BLM collects this information to determine that testing and testing results of BLM-approved measurement equipment are consistent with requirements of BLM regulations at 43 CFR 3175.41. Response to this request is required to obtain or retain a benefit, see 43 CFR Subpart 3175.41. 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 80 hours 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 (OMB No. 1004-0004), Bureau Information Collection Clearance Officer (HQ-630), 1849 C Street, N.W., Mail Stop 401 LS, Washington, D.C. 20240.