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FES-18-2014 01:22P FROM:(LJIZNDS SUB '3035674263 Td:17195502800 P.1 UNITED STATES R'wm 3330-7 DEPARTMENT OF THE KMRiOR (September 2010) BUREAU OF LAND MANAGEMENT FORM APPROVED MAINTENANCE FEE WAIVER CERTIFICATION OMB NO.100"114 Expires: August 3 t,2010 SEE INSTRUCTIONS ON PAGE 2 t. This small miner waiver is filed for the assessment year beginning on September 1,2gAL and ending on September 1, 2. The undersigned and all related patties owned tat or fewer mining claims,mill,or umnal sites located and maintained on Federal lands in the United States of America on September I, i2gd 3.The undersigned have perAnmed the assessment work required by taw fbr each mining claim listed prior to filing this waiver stuff understand that by filing this farm,an affidavit of asseu new work must be recorded by the December 30th following the fi ling of this waiver. 4.The undersigned understand the if the assessment work obligation has not yet corm duo under 30 U.S.C.28(for those claims in their first useseineat year only).a notice of intent to hold recldng this condition smut be recorded by the December 30th following the filing of this waiver. 3.The undersigned understand Ow grill and bumsl sits mey also be listed upon this waiver and be waived from psynmtt of tits maintanance fee,and that a nodoe of hstatnt to hold for drew sites is requked to be receded by the December 30th Immediately following the filing of this waiver. 6.The undersigned understand and ukRowk d s that pursuant to 43 U.S.C. 1212 and IS U.S.C.1001,the tiling or recording of a foist,fictitious,or it'audulertt do atmemt with the Bureau of Land Management may result M a tine of up to 5230,000,a prison term not to exceed five years,or both, 7.The minint clsi mill or tunnel sites for which this waiver from payment of Ow fees is reausm are! CLAIM OR SITE NAME BLM RECORDATION SERIAL NUMBER +� xArz A.4 o Q F 11Z 171 oft v3' r' / 040 q o n r. t t 2 L fir 6�, !I /.t ✓6• ASA, R ,f 2 IJUNJ 04•ak Ag 244 M ✓R -1-y- meliat Af dl& 3 5k y A&dAw 49 2A2 10. The owner/(s)(claimants)rat'iid rt mtttiag claims and sites are: �1►i t;J G BrLA pjee.a3u r-A.I&aw". (Owna'al4eG -piccasc Print) I 49wnees Signawre) /Z,t A.itE(SSOW ska or P.O.Box) ...._�._ . ................. . .. ........ ..............................................................._................... (Owners Name-Please Print) �— (Owner's Signature) �; '.a w <nr•+ ;«�� (Sow or P.O.Sox) - (City) ( ). (Zip Code) .. .... ............................................................ ....i3[.:............ • Y (Owner's Name-Please Print) (Owner's Signature) (Streat or P.O,Box) (City) (State) (Zip Cods) M—Onfinued on osae 21