U.S. DEPARTMENT OF THE INTERIORBUREAU OF LAND MANAGEMENT
Wyoming

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Rock Springs Field Office

Request for Wildlife Exception

You must select one "Project Category."
Project Category: Fluid minerals/APD  Realty action/ROW Other
Note: please use a period as a separator instead of a hypen or slash  (e.g. 01.25.10 instead of 01-25-10 or 01/25/10)

Project Information Provided by Proponent
Project Name: Request number: Date submitted:
Company/Group requesting exception:
Project Contact Name: Title:  
Phone Number: Email:  
BLM Contact Name (NRS, Realty, Range):
Type of Project:  Fluid minerals/APD      Realty action/ROW      Other
Lease or Case File Number:
Location:    
Date Action (APD/ROW) Approved:
Proposed Exception Start Date:
Exception Requested Until Date (approval limited to 14 days):

Affected Resources (check all that apply within request time period)
        Crucial Winter Range
        Raptor Nesting (list species if known):
        Sage-grouse
        Mountain plover
        Parturition/Calving/Lambing Habitat
        Other Species or Seasonally Restricted Habitats (list if known):

Statement of Work
Statement of need for the exception, including alternatives considered & impact of delay:
Actions/construction to be completed, including workforce & equipment required:
Anticipated start date & time frame required for actions/construction:
Next logical stopping point:
Attachments:
To send attachments via email, send to rock_springs_wymail@blm.gov.
Or fax to 307-352-0329 with "Exception Request" as the subject.		 Quality map Additional activity descriptions Other
Additional Information?
Leave This Field Blank      
Please contact BLM_WY_WebTeam@blm.gov if you receive an error message after clicking "Submit."