Form 4120-7 Range Improvement Permit

Xxxx, 2013) UNITED STATES DEPARTMENT OF THE INTERIOR BUREAU OF LAND MANAGEMENT APPLICATION AND APPROVAL FOR RANGE IMPROVEMENT PERMIT FOR REMOVABLE AND/OR TEMPORARY IMPROVEMENTS	FORM APPROVED OMB NO. 1004-0019 Expires: xxxxxxx xx, 2013
	FOR BLM USE ONLY
	State Code……………….. Office Code……………… Authorization Number....... Allotment Number………. Project Number…………..
INSTRUCTIONS -Type or print plainly in ink. Applicant completes form through "Signature of Applicant" and "Signature Date." Signatures must be handwritten in ink. Applicant then submits permit application to the appropriate Bureau of Land Management (BLM) Field Office for approval. Upon approval, BLM returns the original to the applicant, and files one copy in the applicant's grazing case record and one copy in the BLM project record.
	Date Filed

Form 4120-7 (

_{Name (last, first, middle initial) Mailing Address (include zip code)}

_{Applies for a permit to}

_{construct, maintain, and use}

_{maintain and use in connection with the applicant’s grazing permit or lease, and subject to the permit conditions}

_{set forth below, the following described removable and/or temporary improvement on public lands:}

_{The purpose, need, and use for such improvement is as follows:}

If this permit is for a new project, specifications for this improvement must accompany this application.

_{The improvement is to be located in Section , Township , Range ,}

_Meridian,

County of

, State of . The location is shown on the diag_{ram on page 2 hereof.}

Estimated cost of improvement is: $

_{Estimated present value of the improvement is $}

, for labor and/or; $

, for materials which will be paid for or furnished by the applicant.

Signature of Applicant Signature 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, fictitious, or fraudulent statements or representations as to any matter within its jurisdiction.

FOR BLM USE ONLY

PERMIT CONDlTlONS AND APPROVAL

_{A permit is hereby issued subject to the following conditions:}

1. The permit will cover only such portions of temporary or removable range improvements and livestock handling facilities as are actually located

upon public lands. Examples of removable or temporary facilities and improvements are: corrals, creep feeders, loading chutes, and portable storage tanks and troughs for hauled water.

2. The permit does not convey right, title, or interest in any lands or resources held by the United States.

3. The permit is subject to cancellation in whole or in part if the lands or portions thereof are disposed of or devoted to a public purpose which precludes livestock grazing.

4. The permittee must maintain the improvement in good working

order and in an aesthetic state. The permittee will comply with laws of the State within which the improvements are listed.

5. Any public lands or livestock waters will be available for wildlife use, wild horses and burros, and open to the public for hunting and fishing in accordance with State regulations. Such lands and water will also be open for other authorized public use to the extent that such use is consistent with the multiple-use management objectives for the area.

6. The permittee must comply with the construction specifications attached and any special conditions made a part of the permit. Special

conditions and/or specifications attached: Yes No

7. BLM may modify or cancel this permit if the improvement no longer serves the purpose for which it was installed or if the improvement is not compatible with the multiple-use objectives for the area. BLM may cancel this permit if the permittee does not comply with the regulations under which the improvement is authorized (43 CFR Part 4100).

8. Within thirty (30) days after completion of the improvement, the permittee must advise the BLM in writing: (a) the date the job was completed; and (b) total cost of the job, specifying separately the cost of labor and materials.

9. This permit is subject to the provisions of Executive Order No. 11246 of September 24, 1965, as amended, which set forth the nondiscrimination clauses. A copy of this order may be obtained from the BLM.

10. If the permit is for construction of any improvement, it will become void without further notice if the improvement is not constructed by:

(Month) (Day) (Year)

Approved by BLM (printed name, signature, and title)			Date Approved

(Continued on page 2)

For unsurveyed lands, attach U.S.G.S. quadrangles or sketch maps

to show improvement location.

LOCATION PLAT

_{Sec. , T. , R. , Mer.}

Scale: inches equals one mile

TO BE FILLED IN UPON COMPLETION OF IMPROVEMENT

This improvement has been completed satisfactorily on , 20 , at a cost of

_{$ for materials and $ for labor, in accordance with conditions of the permit.}

^{Date of Inspection} Printed Name of Inspecting Officer ^{Signature of Inspecting Officer}

NOTICES

The Privacy Act and 43 CFR 2.48(d) require that you be furnished with the following information in connection with the

information requested by this form.

AUTHORITY: 43 U.S.C. 315, 43 U.S.C. 1752, 43 U.S.C. 1181d, and 43 CFR subpart 4120 permit collection of the information

requested by this form.

PRINCIPAL PURPOSE: The BLM will use the information you provide to develop a permit for the construction, use, and maintenance

of range improvements on its public lands.

ROUTINE USES: In accordance with the Bureau of Land Management’s (BLM) System of Records Notice published in the Federal Register on December 29, 2010 [Bureau of Land Management’s Range Management System—Interior, LLM-2; Notice To Amend an Existing System of Records; Privacy Act of 1974; as Amended], names and addresses provided by the applicant on this form will be publically available in reports on the BLM public website.

EFFECT OF NOT PROVIDING INFORMATION: Submission of the requested information is necessary to obtain or retain a benefit. Failure to submit all of the requested information or to complete this form may result in delay or the rejection and/or denial of your application.

The Paperwork Reduction Act requires that you be furnished with the following information in connection with the information

requested by this form:

BLM collects this information to authorize range improvements on public lands. Response to this request is required in order to obtain or retain a benefit.

You do not have to respond to this or any other Federal agency-sponsored information collection unless it displays a valid OMB control number.

BURDEN HOURS STATEMENT: The public reporting burden for this form is estimated to average 2 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 (1004-0019), Bureau Information Collection Clearance Officer (WO-630), 1849 C Street, NW, Room 2134LM, Washington, D.C. 20240.