Form 3809-5
(January 2017)
UNITED STATES
DEPARTMENT OF THE INTERIOR
BUREAU OF LAND MANAGEMENT
FORM APPROVED
OMB No. 1004-0194
Expires: January 31, 2020
NOTIFICATION OF CHANGE OF OPERATOR AND ASSUMPTION OF PAST LIABILITY
The mining law surface management regulations at 43 CFR 3809 require that obligations accrued or conditions created under an operation
remain with that operator until (1) Bureau of Land Management (BLM) accepts a satisfactory replacement nancial guarantee adequate to
cover the previously accrued obligations and (2) BLM receives documentation that a transferee accepts responsibility for the transferor’s
previously accrued obligations. Therefore, the undersigned transferee hereby assumes all liabilities that may be outstanding on the plan of
operations or notice shown below, including, but not limited to, the obligation to properly reclaim and restore the land disturbed on said
plan or notice within the approved reclamation plan or notice led with the BLM; provided that the obligation will not act to increase the
potential or cumulative liability above the face amount of the replacement bond to which this notication attaches in the amount stated
below as required from the transferee.
1. BLM Notice or Plan of Operations Number(s):
2. Date BLM Accepted Notice or Approved the Plan of Operations:
3. Change of operator on the Notice(s) or Plan(s) shown is proposed on
as follows:
(Date)
FROM: Current Operator (Transferor)
Address
Address
By
(Print Name)
Signature
Title
Surface Reclamation Bonding Amount Currently Obligated: Sum of
U.S. dollars ($
).
TO: Proposed Operator (Transferee)
Address
Address
By
(Print Name)
Signature
Title
Surface Reclamation Bond: Sum of
U.S. dollars ($
).
(TIN or SSN)
Change of Operator Approved Pending Acceptance of Satisfactory Bond:
(Field Manager)
(Date)
cc: State Ofce
Surety, if applicable
(Continued on page 2)
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
