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I:UitM (1pPROV�i) <br />Dorm 350 -1 UIv1B NO. 1004 -0114 <br />(]u luU3) UN1'I'I.I� S'1'A'1'IiS Expires: piny 31, 1996 <br />UL•1'Alil'M1;N "1 Or "III NAGL•ME�T <br />BUItLAU OT LAND MA• <br />ct= R"TIFICATION OF E.XEMP�ION FROMPA`tN1�ta� �F RE���LFEE <br />SEE INSTRUCTIONS ON FLAP <br />this small miners exemption is filed for the assessment year beginning at noon on September 1, 199 , and ending at noon on September 1, 19� <br />'11te undersigned owncr(s) of the mining claim listed below hereby certify under penalty of 18 U.S.C. 1()01 and 43 U.S.C. 1212 That: o <br />1/We own tell or fewer mining claims /sites located and maintained in the Ur:itcd States of Amcrica. <br />I/ Ve have a total of less than ten acres of unreclaimed surface disturbance on the claims /sites resulting from exploration or mining activities. <br />The ten or fewer mining claims listed below are operated under a Notice, Plan of Operations, Spccial Use Permit, or other State Or local p <br />dc.cribed in the regulations nt 43 ClU 3833.1 -6, issued by: 0 T C5 K ✓/ L w/t'r ,5 i ✓o <br />p.: 0 4 k. s r A I r— A-, f{. *.vc --, K 0, s 7-1-�.1 ter, <br />and the serial number or other designation of such Notice, Plan of Operations, or Permit is: RF t:1 / VSO $" <br />6 -43 0 't3''F�� <br />✓ V C- r9— n, y T O 6 i 'S Iq . <br />Please check the appropriate box indicating production or exploration that applies to your claims, and complete the production lufon <br />that applies. <br />❑ I/"Vc have produced from the mining claims /sites listed below more than 51,500 and less than SM),0(HI in gross revenues of a <br />commodity(ics) during the above assessment year that are subject to the General Mining Law of 1872, as amended; the Act of October 5, 1 <br />regulations nt 43 CFR 3833.1 -6 and 3850. <br />COMMODI'IY01, GROSS DOLLAR VALUE PRODUCED <br />Cl I!1Vc lave or will pc: C01111ixPlorn upon the lode and/or placer claims fitted below that meets the requiremeim of the General Nli <br />If 1872, as wrrerrded; the Act of October 5, 1992; and the regulations ai 43 CFR 3833.1 -6 and 3850. Such work will he described on our aI <br />labor. <br />The lode and /or placer claims for which the above exemption from payment of the rental fees is made arc: <br />CLAItef NAbfL: <br />BLNi RECORDATION SERIAL. NUMBER <br />COUNTY <br />RL'CORDA'110N <br />BOOK <br />2- <br />A <br />3 /5-0 <br />I2 -)(0 <br />a 9y <br />l <br />i <br />3 <br />9VC <br />(t.untl nrcu on reverse) <br />