Permittee Report of Road Use

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Permittee Name/Contact/Bill Address: ↓

United States Department of the Interior
Bureau of Land Management - Oregon State Office
PERMITTEE REPORT OF ROAD USE
Permit No.:↓

Serial No.:↓

Period From↓:

Period To↓:

Form OR 2812-6 (February 2017)
OMB 1004-0168; Expiration 10/31/2026

Page 1 of _____

(for this reporting period)
↓BLM responsible for this portion↓:

↓Permittee fills in this portion↓:
Material Hauled From:

Road Use Fees

Maintenance Fees

Surface
Replacement Fees

Quantity
hauled
(MBF in
Long
Log)*

Alloc. or
NonFee/
Amount
Length
Alloc.
Road Use Due (NTE
Fee/
MBF/
Permittee Project Name
Road
used
Surface
(A or
Fee/MBF Current Def. MBF/Mi. Amount
Mi.
T. R. Sec.
BLM Road No. Segment
(optional)
(Mi.)
Type
Non)
($)**
Used
Due
Used Amount Due
Bal.)
$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 requried 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 1 hour 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.

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↓:

↓Permittee fills in this portion↓:

R.

Sec.

Permittee Project Name
(optional)

OMB 1004-0168; Expiration 08/31/2023

Period To↓:

Page _____ of _____

(for this reporting period)

↓BLM responsible for this portion↓:

Material Hauled From:

T.

Form OR 2812-6a (February 2017)

Road Use Fees

Maintenance Fees

Surface Replacement
Fees

Alloc. or
NonAlloc.
Road Use Amount Due Fee/
Fee/
Road
(A or
Fee/MBF (NTE Current MBF/Mi. Amount MBF/ Mi.
BLM Road No. Segment
Non)
($)**
Def. Bal.)
Used
Due
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
$0.00
$0.00
$0.00
TOTALS THIS PAGE (BLM TRANSFER TO PAGE 1)→
Quantity
Length hauled
used
(MBF in Surface
(Mi.) long log)* Type

PERMITTEE CERTIFICATION for this continuation sheet:

← Initial here to indicate that certification on page one applies to this page as well.

BLM Verification:

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.