Form 3604-1a
(February 2017)
NO. 1004-0001 Expires
December 31, 2019
Name of applicant Telephone Email
Mailing Address Street Address (if different from Mailing Address)
State Zip code
City State
Zip code
Kind of material Quantity requested cu.yds.
or tons
Requested permit term
Materials are to be used for:
Give legal land description for proposed source area:
Select one
Meridian Township Range Section Subdivision Acres Existing Mine Site
New Mine Site
I HEREBY AGREE TO COMPLY WITH the regulations at 43 CFR Part 3600 and the stipulations and special conditions as set forth in the permit. I
CERTIFY that the: (a) materials to be removed will be used for the purpose noted above; (b) none of the materials removed will be sold or bartered;
(c) removal of materials will begin only upon receipt of an approved copy of this permit and will cease upon the expiration date or removal of the
authorized quantity, whichever comes rst; and, (d) the Bureau of Land Management (BLM) will be notied upon completion of removal.
I CERTIFY that I am of the age of majority in the State in which I reside, and that this entity is qualied to apply for a free use permit to extract and
use mineral materials under 43 CFR 3604.12 as a
(Select one)
Federal, State, or territorial agency, unit, or subdivision (including municipalities), or non-prot organization.
I FURTHER CERTIFY That the statements made by me in this application are true, complete, and correct to the best of my knowledge and belief, and
are made in good faith.
of Applicant) (Date)
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.
If you are a non-prot organization or quasi-governmental agency, attach organization charter and other proof of status.
The Privacy Act of 1974 and the regulations in 43 CFR 2.48(d) provide that you be furnished with the following information required by this
AUTHORITY: 30 U.S.C. 601; and 43 CFR Part 3600
PRINCIPAL PURPOSE: BLM uses the information to maintain an inventory of mineral information, to adjudicate your rights to mineral resources,
and to identify the parties applying for and/or granted permits for disposing of mineral materials.
ROUTINE USES: BLM will disclose the information on this form pursuant to the regulations in 43 CFR 2.56.
EFFECT OF NOT PROVIDING THIS INFORMATION: If you do not furnish all the information required by this form, your application may be
The Paperwork Reduction Act of 1995 requires us to inform you that:
The BLM collects this information to evaluate the amount and condition of mineral materials on public lands and it will be used to maintain depletion
The BLM is collecting this information to process your application and effect a binding permit.
The BLM will use this information to identify and communicate with applicants.
Response to this request is required to obtain a benet.
The 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: The combined public reporting burden for Forms 3604-1a and 3604-1b is estimated to average 45 minutes to
complete both forms, 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-
0001), Bureau Information Collection Clearance Ofcer (WO-630), 1849 C Street, N.W., Mail Stop 2134LM, Washington, D.C. 20240.
(Form 3604-1a)