Form 3510-2
(Aug 2016)
OMB NO. 1004-0121
Expires: August 31, 2019
Serial Number
Phosphate – act of February 25, 1920
(41 Stat. 441; 30 U.S.C. 214)
Sodium – act of February 25, 1920
(41 Stat. 447; 30 U.S.C. 263)
The Bureau of Land Management (BLM), pursuant to the above-cited act, hereby grants to:
the holder of a permit lease bearing the above Serial Number, the right so long as needed, used, and occupied, during the
life of the permit or lease, the use of the surface of the following-described land:
for a campsite, rening works, and other purposes connected with
and necessary to the proper development and use of the deposits
covered by the permit or lease consistent with the terms of the
permit or lease. All rights hereunder to cease and terminate upon
the termination of the permit or lease.
Dated as of the rst day of
, 20
(Name - Print)
(Signature of BLM)
The annual charge for this permit is $ an acre,
or fraction thereof, for the area covered hereby payable on or before
the anniversary date of this permit.
Title 18 U.S.C. Section 1001 and Title 43 U.S.C. Section 1212 make it a crime for any person knowingly and willfully to make to any
department or agency of the United States any false, ctitous, or fraudulent statements or representations as to any matter within its jurisdiction.
(See Instructions and Equal Opportunity Clause on page 2) (Form 3510-2 , page 1)
Prepare original and four (4) copies. Submit all copies
to BLM for signature on original and rst copy.
Original is assembled with the case record; rst copy is
sent to the lessee or permittee; and three (3) copies are
sent to the Mining Supervisor of the Geological Survey.
During the performance of this contract, the permittee agrees as
(1) The permittee must not discriminate against any employee
or applicant for employment because of race, creed, color, sex,
or national origin. The permittee must take afrmative action to
ensure that applicants are employed, and that employees are treated
during employment, without regard to their race, creed, color, sex,
or national origin. Such action must include, but not be limited
to the following: employment, upgrading, demotion, or transfer;
recruitment or recruitment advertising; layoff or termination;
rates of pay or other forms of compensation; and selection for
training, including apprenticeship. The permittee agrees to post
in conspicuous places, available to employees and applicants for
employment, notices to be provided by the contracting ofcer
setting forth the provisions of this nondiscrimination clause.
(2) The permittee must, in all solicitations or advertisements for
employees placed by or on behalf of the permittee, state that all
qualied applicants must receive consideration for employment
without regard to race, creed, color, sex, or national origin.
(3) The permittee must send to each labor union or representative
of workers with which he has a collective bargaining agreement
or other contract or understanding, a notice, to be provided by the
agency contracting ofcer, advising the labor union or workers’
representative of the permittee’s commitments under Section 202 of
Executive Order No. 11246 of September 24, 1965, and must post
copies of the notice in conspicuous places available to employees
and applicants for employement.
(4) The permittee must comply with all provisions of Executive
Order No. 11246 of September 24, 1965, and of the rules,
regulations, and relevant orders of the Secretary of Labor.
(5) The permittee must furnish all information and reports required
by Executive Order No. 11246 of September 24, 1965, and by the
rules, regulations, and orders of the Secretary of Labor, or pursuant
thereto, and must permit access to his books, records, and ac-
counts by the contracting agency and the Secretary of Labor for
purposes of investigation to ascertain compliance with such rules,
regulations, and orders.
(6) In the event of the permittee’s noncompliance with the
nondiscrimination clauses of this contract or with any of such rules,
regulations, or orders, this contract may be cancelled, terminated
or suspended in whole or in part and the permittee may be declared
ineligible for further Government contracts in accordance with
procedures authorized in Executive Order No. 11246 of September
24, 1965, and such other sanctions may be imposed and remedies
involved as provided in Executive Order No. 11246 of September
24, 1965, or by rule, regulation, or order of the Secretary of Labor,
or as otherwise provided by law.
(7) The permittee must include the provisions of paragraphs
(1) through (7) in every subcontract or purchase order unless
exempted by rules, regulations, or orders of the Secretary of Labor
issued pursuant to Section 204 of Executive Order No. 11246 of
September 24, 1965, so that such provisions will be binding upon
each subcontractor or vendor. The permittee must take such action
with respect to any subcontract or purchase order as the contracting
agency may direct as a means of enforcing such provisions
including sanctions for noncompliance: Provided, however, That
in the event the permittee becomes involved in, or is threatened
with, litigation with a subcontractor or vendor as a result of such
direction by the contracting agency, the permittee may request the
United States to enter into such litigation to protect the interests of
the United States.
(Continued on page 3) (Form 3510-2 , page 2)
The Privacy Act of 1974 and the regulation, in 43 CFR 2.48(d) provide that you be furnished with the following information required by this
AUTHORITY: 30 U.S.C. 181 et seq, 43 U.S.C. 3500
PRINCIPAL PURPOSE: BLM will use the information you provide to determine whether or not to issue you a use permit for your phosphate
or sodium lease and, if you qualify, will issue you the permit on this form.
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
proceeding 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 information is required to obtain and keep a benet. If you do not provide
the information, BLM may not issue a use permit to you.
The Paperwork Reduction Act of 1995 requires us to inform you that:
BLM collects this information to comply with the regulations at 43 CFR 3500, which implement the provisions of the Mineral Leasing Act
of 1920, as amended; the Mineral Leasing Act for Acquired Land of 1947; and section 402 of Reorganization Plan No. 3 1946.
BLM uses this information to determine whether or not you qualify for a use permit for your sodium or phosphate lease.
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 3510-2 , page 3)