Form FS-2400-1/BLM-5450 Forest Products Removal Permit and Cash Receipt

FS-2400-1 BLM-5450-24 (05/2005)

FOREST PRODUCTS REMOVAL PERMIT and CASH RECEIPT U.S. DEPARTMENT OF AGRICULTURE – FOREST SERVICE U.S. DEPARTMENT OF THE INTERIOR – BUREAU OF LAND MANAGEMENT

OMB No.: 0596-0085 Expires: XX/XX/XXXX

FS Region/BLM State:      

FS National Forest/BLM District:      

FS Ranger District/BLM Field Office:      

Permittee's Name and Complete Address:

Permit No.

Preparation Date

Payment Method

Name:

     

     

     

     

Address:

     

Effective Date

Termination Date

Load Ticket Numbers

     

     

     

From:      

Thru:      

City/State:

     

Product Plan

From:      

Thru:      

Zip Code:

     

Number:      

Name:      

Permittee Identification

Type

Public Land Type

County

     

     

     

     

Vehicle(s) Information

Associated Charges

Permit Area Description:

Year:

     

Year:

     

Fund

Amount

     

Make:

     

Make:

     

     

     

Model:

     

Model:

     

     

     

Color:

     

Color:

     

     

     

License:

     

License:

     

     

     

State:

     

State:

     

     

     

Remarks:      

PRODUCT DESIGNATION

Product

Species

Unit of Measure (UOM)

Quantity Sold

Rate per Product UOM

Assoc. Charges $ per UOM

Total Cost of Products ($)

Cost of Assoc. Charges ($)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Total Permit Costs:

     

     

Total Purchase Price:

     

PRODUCT QUANTITY REMOVAL RECORD

Date

Time

Quantity Removed

Date

Time

Quantity Removed

Date

Time

Quantity Removed

Date

Time

Quantity Removed

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

For BLM lands only, Permittee certifies that they are of the age of majority in the state they reside in and, if purchasing timber, are a United States citizen

SIGNATURES

     

     

PERMITTEE

Date

AUTHORIZED AGENCY/VENDOR

Date

PRIVACY ACT NOTICE The following information is provided to comply with the Privacy Act of 1974 (PL-579). 5 U.S.C. 552a authorizes acceptance of the information requested on this form. The Forest Service and Bureau of Land Management use this information to maintain an inventory of forest product information and to adjudicate your rights to forest products. The information required by this form may be disclosed pursuant to the regulations in 7 CFR 1.5 or 43 CFR 2.56. If you do not furnish all the information required by this form, your application may be rejected. BURDEN AND NONDISCRIMINATION STATEMENTS According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0085. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

Permit No.:      
GENERAL CONDITIONS
Subject to, and in strict compliance with, all the following conditions (both General and Other) and those listed above, the Permittee named herein is authorized to harvest and remove the forest products described above. This sale is final and payments are not subject to refund. Permit must be in the Permittee's possession while harvesting and transporting products. Copies are not allowed. This permit is nontransferable. This permit and activities hereunder are subject to all applicable Federal statutes and regulations and State and local laws. In case of conflict, Federal statutes and regulations shall take precedence. Where applicable, a Memorandum of Agreement between the Forest Service and BLM governs administration and enforcement of this permit (Sec. 330, P.L. 106-291). Motorized vehicles are not allowed off existing roads that are open to the public, unless otherwise specified within this permit. Permittee parking shall not block traffic or impede fire or emergency vehicles. Permittee shall remove all trash and litter resulting from Permittee's activities. Concurrent with forest product removal activities, slash and unused vegetative material resulting from Permittee's activities shall be removed from roads and ditches and scattered in the surrounding landscape. Permittee shall comply with fire requirements and current restrictions to prevent forest fires. Permittee shall pay for or repair all damage to natural features; riparian areas; other vegetation; and roads, trails, fences, ditches, telephone lines, or other improvements resulting from Permittee's activities under this permit. The Forest Service and/or BLM reserve the right to unilaterally revoke this permit for Permittee's noncompliance with its terms and conditions or when revocation is in the public's interest. Regardless of whether forest products are removed, this permit will terminate either at midnight of the termination date shown above, or when the quantity listed above is reached, whichever comes first. None of the terms or conditions of this permit may be varied or modified, except for unilateral modifications by the Forest Service and/or BLM. Permittee agrees to hold the Government harmless from any claim for damage or loss of property, personal injury, or death. Collection of forest products is permitted only in the area(s) described by this permit. Permittee shall complete the Product Quantity Removal Record in ink prior to transporting products. When load tickets are issued, the Permittee is required to complete load tickets when Permittee moves between collection sites or leaves a permit area. Load tickets must be securely attached to the load and clearly visible from the rear of the vehicle.
OTHER CONDITIONS