Form 3195-3
(November 2018)
ATTN: Assistant Field Manager for Operations
801 S. Fillmore, Suite 500
Amarillo, Texas 79101
OMB Control No. 1004-0179
Expires: October 31, 2021
Reners’ Tolling Occurrence Report
FISCAL YEAR: : Submit within 14 days of entering into a tolling agreement
Volumes in million scf/yr
Date Tolling
Agreement Signed Volume
(Per MCF) Delivery Period
I certify that the information provided above accurately describes the recent tolling agreement with a non-rener 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 reners’ data for the BLM’s purposes.
Company Name: Title:
Telephone: Printed Name of Authorized Agent:
Email: 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 rened helium deliveries. The BLM uses this information to monitor compliance with a
statutory requirement that sellers of rened helium to federal agencies buy an equivalent amount of crude federal helium. Responses
are required to obtain or retain a benet (43 CFR 3195 and 50 U.S.C. 167d(b)(8)). In order to ensure the condentiality 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 Ofcer (WO-630), Washington, DC 20240.
(Form 3195-3)
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