(If “Yes,” give name of agency)
6. Are the lands administered by a government agency?
Form 3510-1
(Aug 2016)
OMB NO. 1004-0121
Expires: August 31, 2019
1. Serial Number (See Specic Instructions - Item 1)
2. What mineral(s) are you applying for?
3a. Applicant’s name
3b. Applicant’s address
4. Give legal description of land requested (See General Instructions, Item 4)
5. Legal description of land included in permit
Total acres Rental submitted $ Total acres Rental retained $
(See Specic Instructions - Item 7)
7. Are you the sole party in interest?
8a. Are you a citizen of the United States?
8b. Are you over the age of majority?
Yes No
9a. Is application made for a corporation or other legal entity?
(If “Yes,” see Specic Instructions - Item 9a)
9b. Has a statement of qualication been led? No (If “Yes,” give le number, if “No,” see regulation 43 CFR 3502)
10. A processing fee will be determined on a case-by- 11. Be sure to enclose the rst years advance rental computed at the rate
case basis. (See Specic Instructions - Item 10) of 50¢ per acre or fraction thereof (See Specic Instructions - Item 11)
I CERTIFY That my interests, direct or indirect, in leases, permits, and applications therefor, do not exceed the maximum permitted by law or
regulation, and that the statements made herein are true, complete, and correct to the best of my knowledge and belief and are made in good faith.
(Signature of Applicant) (Signature of Applicant)
(Date) (Attorney-in-fact)
Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any false,
ctitious or fraudulent statements or representations as to any matter within its jurisdiction.
(Name of Mineral(s)
A permit for the lands in Item 5, above, is hereby issued under the
below) and is subject to all regulations found in 43 CFR 3500 and to the
terms and conditions set forth on the reverse hereof.
Other Special Act(s) (as indicated
Mineral Leasing Act, 30 U.S.C. 181 et seq.,
Acquired Lands Leasing
Act, 30 U.S.C. 351 et seq.,
Section 402 of Reorganization Plan No. 3
of 1946, 5 U.S.C. Appendix 1031,
This permit, to the extent applicable, is subject to standard and/or special
Stipulations if any are attached.
Effective date of permit
This permit is issued for a period of years
(Title) (Date)
(Continued on page 2) (Form 3510-1, page 1)
Sec. 1. Rights conferred by issuance of prospecting permit. Permittee
is granted the exclusive right to prospect on and explore the lands to
determine the existence of a valuable deposit of the mineral applied
for or any compound of that mineral in accordance with the terms and
conditions of the permit. Permittee must diligently prospect the lands by
core drilling or other acceptable methods. The permittee may remove only
such material as is necessary to demonstrate the existence of a valuable
mineral deposit.
Sec. 2. Operating regulations. (a) Pennittee must comply with all
regulations of the Secretary of the Interior; and, as to the lands described
herein under his jurisdiction, to the regulations and orders of the Secretary
of Agriculture.
(b) Permittee must comply with the provisions of the operating
regulations of the Bureau of Land Management (BLM) (43 CFR 3590)
and all orders issued pursuant thereto. Copies of the operating regulations
may be obtained from the BLM.
(c) Permittee must maintain a permit bond in the amount determined by
the BLM.
(d) Permittee must allow inspection of the premises and operations by
representatives of the Departments of the Interior, Agriculture, or other
agency administering the lands and provide for the free ingress and egress
of Government ofcers and users of the lands under authority of the
United States.
Sec. 3. Multiple use. (a) Valid existing rights acquired prior hereto on the
lands described herein will not be adversely affected hereby.
(b) The granting of this permit will not preclude the issuance of other
permits, leases, or other development of the same lands.
(c) The permitted lands will be subject, at all times, to any other lawful
uses by the United States, its lessees, permittees, licensees, and assigns,
but such use should not materially interfere with the permittee’s operations
(d) The Government reserves the right to sell or otherwise dispose of
the surface of the permitted lands under existing law or laws hereafter
enacted, insofar as such disposal will not materially interfere with the
rights of the permittee.
(e) The permittee must afford all facilities for inspection of the
prospecting work on behalf of the Secretary of the Interior or head of
agency administering the lands and to make a report, on demand, of all
matters pertaining to the character, progress, and results of such work.
(f) The permittee must observe such conditions as to the use and
occupancy of the surface of the lands as provided by law, in case any of
said lands will have or may be entered or patented with a reservation of
mineral deposits to the United States.
Sec. 4. Removal of deposits. Permittee must remove from the lands only
such deposits as may be necessary to experimental work or to establish
the existence of valuable deposits within the permit area and must keep a
record of all minerals mined.
Sec. 5. Rental. Permittee must pay an annual rental of 50 cents per acre, or
fraction thereof, but not less than $20 per year. The annual rental payment
must be made on or before the anniversary date of the permit, payable to
Minerals Management Service.
Sec. 6. Extension of permit. (a) This permit may be subject to extension
under applicable regulation upon approval by the Bureau of Land
Management (BLM) and upon the showing of entitlement hereto. (No
extension may be granted for sodium or sulphur prospecting permits.)
Sec. 14. Special Stipulations:
to the date of expiration of this permit. Unless such an application is led
within the time specied, this permit will expire without notice to the
(b) Application for extension of this permit, where authorized by law or
regulation, must be led in the proper BLM ofce at least 90 days prior
Sec. 7. Assignments. All assignments or transfers of this permit or of any
interest therein must be led with the BLM for approval in accordance
with the provisions of the appropriate regulation and will take effect as
of the rst day of the month following approval thereof, or, if transferee
so requests, as of the rst day of the month during which such approval
is given.
Sec. 8. Relinquishment of permit. Permittee may relinquish this permit, in
whole or part, by ling in the proper BLM ofce a written relinquishment
which, upon acceptance by the BLM, will be effective as of the date of
Sec. 9 Termination or cancellation. (a) This permit will terminate
automatically upon failure of the permittee to pay the rental on or before
the anniversary date thereof.
(b) This permit may be cancelled in accordance with the regulations upon
failure by permittee to comply with the regulations or the provisions of the
law, or for violation of any of the terms or stipulations of the permit and
exploration plan. Such cancellation may occur if such failure or default
continues for 30 days after service of written notice thereof by the BLM.
Sec. 10. Protection of surface, natural resources, and improvements.
The permittee agrees to take such reasonable steps as may be needed to
prevent operations on the permitted lands from unnecessarily: (1) causing
or contributing to soil erosion or damaging crops, including forage, and
timber growth thereon or on Federal or non-Federal lands in the vicinity;
(2) polluting air and water; (3) damaging improvements owned by the
United States or other parties; or (4) destroying, damaging or removing
fossils, historic or prehistoric ruins, or artifacts; and upon any partial or
total relinquishment or the cancellation or expiration of this permit, or
at any other time prior thereto when required and to the extent deemed
necessary by the lessor to ll any pits, ditches and other excavations,
remove or cover all debris, and so far as reasonably possible, restore the
surface of the permitted land and access roads to their former condition,
including the removal of structures as and if required. The BLM will
prescribe the steps to be taken and restoration to be made with respect to
the permitted lands and improvements thereon whether or not owned by
the United States.
Sec. 11. Antiquities and objects of historic value. When American
antiquities or other objects of historic or scientic interest including but
not limited to historic or prehistoric ruins, fossils or artifacts are discovered
on lands covered by this permit, or discovered during performance of this
permit, the item(s) or condition(s) will be left intact and immediately
brought to the attention of the contracting ofcer or his representative.
Sec. 12. Discovery of Valuable Deposit: A permittee may le an application
for a noncompetitive lease not later than 60 days after expiration of
the prospecting permit. An applicant for a noncompetitive lease must
show that a valuable deposit of the mineral specied in the prospecting
permit was discovered within the permit area and during the life of the
permit. For noncompetitive lease applications for sodium, potassium and
sulphur, it additionally must be shown that the lands are chiey valuable
for that mineral (as opposed to nonmineral disposition of the lands). See
regulations in 43 CFR, Part 3500 for ling requirements for specic
Sec. 13. Equal opportunity clause. This permit is subject to the provisions
of Executive Order No. 11246 of Sept. 24, 1965, as amended, which sets
forth the nondiscrimination clauses. A copy of this order may be obtained
from the BLM
(Continued on page 3) (Form 3510-1, page 2)
Sec. 14. Special Stipulations (Cont.)
Number of copies. Three copies of the application, typewritten or
printed plainly and signed in ink, must be led in the BLM ofce
having jurisdiction for the State in which the lands are located.
If additional space is needed to furnish any of the required informa-
tion, the information should be prepared on additional sheets (8 1/2 x
11”), initialed, and attached to this application.
NOTE: After an initial review and clearance of the application, but
prior to the BLM’s issuance of the prospecting permit, the applicant
will be required to le in triplicate an exploration plan reasonably
designed to determine the existence or workability of the deposit.
See regulations in 43 CFR Part 3500, for Specic requirements
regarding information to be included in exploration plan.
Item 1 - Serial Number will be issued by the BLM at the time the
application is led. Any future correspondence concerning this
application/permit should reference the serial number.
Item 2 -Specify mineral(s) applied for.
Item 4 - Land description: A complete and accurate description of
the lands for which the permit is desired must be given in accordance
with the regulations at 43 CFR 3503. The acreage must not exceed
the maximum permitted by laws or regulations. In instances where
the United States does not own a 100-percent interest in the mineral
deposits in any particular tract, the applicant should indicate the
percentage of Government ownership.
Item 7 - Party in interest: Applicant must indicate whether or not he is
the sole party in interest. If not, the applicant must submit, at the time
the offer is led, a signed statement setting forth the names of the
other interested parties. All interested parties must furnish evidence
of their qualications to hold an interest in this permit, if issued.
Item 9a - Application by a Corporation. If the applicant is a
corporation, an ofcer or authorized attorney-in-fact of the
corporation must submit the information specied in regulation 43
CFR 3502.30.
Application by an Association including a partnership. If the
applicant is an unincorporated association, the application must be
accompanied by a copy of the articles of association together with
a showing as to citizenship and holdings of its members, as are
required of an individual.
Application by a trust: See regulation 43 CFR 3502.29 for specic
Item 9b - Statement of Qualications: If information as to
qualications has been led previously with BLM, reference to that
serial number may be made.
Item 10 - A processing fee will be charged which will be determined
on a case-by- case basis under 43 CFR 3000.11.
Item 11 - Advance rental: An advance rental at the rate of 50 cents
per acre, or fraction thereof, but not less than $20 made payable to
the Department of the Interior - Bureau of Land Management must
be submitted with this application. (For example, the advance rental
payment for an application covering 40.1 acres would be $20.50).
(Continued on page 4)
(Form 3510-1, page 3)
The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d) provide that you be furnished with the following information in connection
with information required by this application.
AUTHORITY: 30 U.S.C. 181 et seq., 351 et seq.; 5 U.S.C. Appendix 1031; 43 CFR 3500
PRINCIPAL PURPOSE: The Bureau of Land Management (BLM) will use the information you provide to process your application for a
prospecting permit.
ROUTINE USES: In accordance with the System of Records titled, “Land and Minerals Authorization Tracking System—Interior, LLM-
32,” disclosure outside the Department of the Interior may be made: (1) To appropriate Federal agencies when concurrence or supporting
information is required prior to granting or acquiring a right or interest in lands or resources, (2) To Federal, State, or local agencies or a
member of the general public in response to a specic request for pertinent information, (3) To the U.S. Department of Justice or in a pro-
ceeding before a court or adjudicative body when (a) the United States, the Department of the Interior, a component of the Department, or
when represented by the government, an employee of the Department is a party to litigation or anticipated litigation or has an interest in such
litigation, and (b) the Department of the Interior determines that the disclosure is relevant or necessary to the litigation and is compatible with
the purpose for which the records were compiled, (4) To an appropriate Federal, State, local, or foreign agency responsible for investigating,
prosecuting, enforcing, or implementing a statute, regulation, rule, or order, where the disclosing agency becomes aware of an indication of
a violation or potential violation of civil or criminal law or regulation, (5) To a member of Congress or a Congressional staff member from
the record of an individual in response to an inquiry made at the request of that individual, (6) To the Department of the Treasury to effect
payment to Federal, State, and local government agencies, nongovernmental organizations, and individuals, and (7) To individuals involved
in responding to a breach of Federal data. The BLM will only disclose this information in accordance with the Freedom of Information Act,
the Privacy Act, and the provision in 43 CFR 2.56(c).
EFFECT OF NOT PROVIDING INFORMATION: Filing of this application and disclosing this information is required to obtain a benet.
If you do not provide the information, BLM may reject your application.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations of 43 CFR 3500, which implement the provisions of the Mineral Leasing Act of
1920, as amended; the Mineral Leasing Act for Acquired Lands of 1947; Section 402 of Reorganization Plan No. 3 of 1946; or other special
leasing acts.
BLM uses the information to identify the applicant and the Federal lands for which the applicant seeks permission to prospect for minerals.
Response to this request is required to obtain and keep a benet.
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 10 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 (1004-0121), Bureau Information
Collection Clearance Ofcer (WO-630), 1849 C Street, N.W., Room 2134 LM, Washington, D.C. 20240.
(Form 3510-1, page 4)