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i <br /> i <br /> i <br /> f I <br /> Page-8- <br /> THE UNITED <br /> STATES OF AMERICA <br /> By Solvay Chemicals,Inc. <br /> (Company or Lessee Name) <br /> Lonny R.Bagley -7 I <br /> (Signing Officer) (Signatur essee) <br /> Deputy State Director,Division of Energy,Lands and Minerals cr-S -I- <br /> (Title) (Title)) <br /> 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 <br /> any false,fictitious or fraudulent statements or representations as to any matter within its jurisdiction. t <br /> NOTICES The Paperwork Reduction Act of 1995 requires us to inform you that: Th <br /> The Privacy Act of 1974 and the regulation in 43 CFR 2.48(d)provide <br /> that you be furnished with the following information required by this BLM collects this information to comply with the regulations at 43 CF: <br /> application. 3500, which implement the provisions of the Mineral Leasing Act ( <br /> AUTHORITY:30 U.S.C. 181 et seq.,43 U.S.C.3500 1920,as.upended;the Mineral Leasing Act for Acquired Land of 194' <br /> PRINCIPAL PURPOSE: The BLM will use the information you and section 402 of Reorganization Plan No.3 of 1946.The BLM uses dI i <br /> provide to verify your compliance with lease terms. information to verify that you are complying with leaseterms.Response I t <br /> ROUTINE USES: The BLM will disclose information to: (1) this request is required to obtain and keep a benefit.The BL,bt would lik <br /> appropriate Federal. State, local or foreign agencies when relevant to you to know that you do not have to respond to this or any other Feder. <br /> civil, criminal, or regulatory investigations or prosecutions; (2) agency-sponsored information collection unless it displays a current) t <br /> appropriate Federal agencies when their concurrence is required before valid OMB control number. c <br /> BLN•I grants a right in public lands or resources; (3)a member of the <br /> public in response to a specific request for pertinent information;(4)a BURDEN HOURS STATEMENT:Public reporting burden for this fin <br /> congressional office in response to an inquiry made at the request of an is estimated to average 300 hours per response, including the time f( " <br /> individual•and(5)to a consumer reporting agency to expedite collecting reviewing instructions,gathering,and maintaining data,and completin <br /> debts owed the government, and reviewing the form.Direct comments regarding the burden estimate( <br /> EFFECT OF NOT PROVIDING INFORMATION: Filing of the any other aspect of this form to U.S.Department of the Interior,Bureau( <br /> information is required to obtain and keep a benefit. If you do not Land Management(1004-012 1),Bureau Information Collection Clearan( <br /> provide the information,BLM may seek to cancel your lease. Officer(WO-630), 1849 C Street,N.W.,Mail Stop 401 LS.Washington <br /> D.C.20240. <br /> t <br /> i <br /> i <br /> {c <br /> i <br />