Form 3510-2 - Phosphate Or Sodium Use Permit

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Form 3510-2
FORM APPROVED
(Aug 2016)
OMB NO. 1004-0121
Expires: August 31, 2019
UNITED STATES
DEPARTMENT OF THE INTERIOR
Serial Number
BUREAU OF LAND MANAGEMENT
Phosphate – act of February 25, 1920
PHOSPHATE OR SODIUM USE PERMIT
(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, refining works, and other purposes connected with
The annual charge for this permit is $
an acre,
and necessary to the proper development and use of the deposits
or fraction thereof, for the area covered hereby payable on or before
covered by the permit or lease consistent with the terms of the
the anniversary date of this permit.
permit or lease. All rights hereunder to cease and terminate upon
the termination of the permit or lease.
Dated as of the first day of
, 20
(Name - Print)
(Title)
(Signature of BLM)
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, fictitous, 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)

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