Form 3604-1b
(
February 2017)
UNITED STATES
DEPARTMENT OF THE INTERIOR
FORM APPROVED OMB
NO. 1004-0001 Expires
December 31, 2019
MINERAL MATERIAL
FREE USE PERMIT
BUREAU OF LAND
MANAGEMENT
Permit (Case) Serial Number
Expiration Date
Permittee Name and Address:
Legal land description of authorized permit area:
Meridian
Township
Range
Section
Subdivision Acres
This permit is issued under the Act of July 31, 1947, as amended, and 43 U.S.C. 2 and 1201. Free use permits are issued subject to the
requirements of 43 CFR Part 3600 now or hereafter in force.
This permit is hereby issued for the materials applied for but may be canceled if it appears that this permit was issued erroneously or the
terms or conditions contained herein are not observed.
The permit is subject to the following standard stipulations:
Any use of the surface of the lands involved in this permit must not interfere with any mining claim subject to the provisions of
Section 4 of the Act of July 23, 1955 (30 U.S.C. 612);
The permittee must allow BLM access for inspections as required by 43 CFR 3601.51
The permittee must clean up all work areas and must remove or dispose of all refuse resulting from the permittee’s operations,
and equipment, personal property, and improvements must be removed within ninety (90) days after the permit expiration date
as required by 43 CFR 3601.52
An annual report indicating the amount (cubic yards or tons) of material removed must be led with the BLM Ofce on
the anniversary date of the permit, and within thirty (30) days after permit expiration.
The permit is also subject to the following SPECIAL CONDITIONS:
Authorized purpose:
Authorized term
Authorized quantity, in-place
years
months days
cubic yards or
tons
Check all that apply:
Permittee Mining and Reclamation plan is required per 43 CFR 3601.40-44
Permittee is responsible for reclamation of permit area
Financial Guarantee is required per 43 CFR 3602.14
Removal area is within Community Pit – Common Use Area - Serial No.
Permittee will perform reclamation in Community Pit – Common Use Area in lieu of reclamation fee
Permittee must follow/comply with BLM mining and reclamation plan
Permittee will pay a reclamation fee for Community Pit – Common Use Area as identied below:
Type of Material
Quantity
(select applicable in-place units)
Reclamation Fee
(select applicable in-place units)
TOTAL Reclamation
Fee
($)
cu. yds. tons
$ per cu. yds. $ per ton
BLM will check this box if there are additional stipulations attached to this permit.
(Continued on page 2)
(Form 3604-1b, page 1)
