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. UNTIED STATES <br />Form 3830 -2 DEPARTMENT OF THE INTERIOR <br />(June 1994) BUREAU OF LAND IvtANAGEMBNT <br />MAINTENANCE FEE PAYMENT WAIVER CER11FiC4 <br />S C- -t-v� o <br />FORM APPROVED <br />b 01v1B NO. 10&WI 14 <br />C v S Expires: March 31.1997 <br />e clzimslsitu Listed below for the assessment ycai beginning at noon on the first September 1 folic <br />'Iieis small miner waiver is filed to hold tit 43 U -S C. 1212 teat: <br />official filing of this form with 13LM certify under pc lty of 18 U.S.C. 1001 <br />The undersigned owners) of the mining ciaims/sites listed below hereby land in the United States of Anicnca on the ' <br />I(YJe epsetrol, or will control. ten or fewer mining daims/sites footed and maintained on Federal <br />of astesstneat year indicated in line one above. fie regulations at d e of 3833 <br />that is one day before the beginning listed below for the current as meat year as of the official lati filing date of this <br />cat wow upon tho claims of 1872, as yrtended- the Act o August I0. 1993: <br />I/Wc have Vcrfonoed assets filed for all sites listed <br />wort: meets the r+e9uiremmts of the General Milting be <br />Such work will be described on of affidavit ng Cement applies a of You - <br />,W to Hotd will <br />C1 Please rh,& this box if the <br />I/fye relinquish atyJottr claiats and/or sires not Listed below. <br />avmcnt of the maintenan a fees is made are-* <br />RECORD <br />SERIAL \t <br />'rtie mining claitns and silts for which the above waiver from p y <br />CLAIM NAME <br />1 A e <br />ti-3 i 9 <br />2- S t- <br />j H <br />3. Lv�S <br />I23 t �f <br />4 L 4 Va. <br />12-3 i g 9 <br />s- H 1 cl ► a <br />t23 i 5�0 <br />6. scurUv1 tov-) <br />123 15' 1 <br />7. Re <br />123 52. <br />a. t3 ^ ✓� � <br />� t 2 3 t .� 3 - <br />9. �fi <br />23 15-4 <br />l0. 13 E <br />of the above mining claims and situ are filing for this waiver. <br />All owncrts) to 43 U.S.C. and 18 U. _ <br />not <br />1001. the filing of a false. fictitious- or frau dulent do <br />to exceed fixe years. or bout. <br />I/We understated and acknowledge that pursuant 00. <br />Bureau of Land Mmaganent tray result to a fine of up to 510.000. a prison term <br />ov► 1 <br />{QWDCS S $IQn3ntre) <br />C�IU. <br />{owners Nan - ease Print) <br />; _ rJ <br />- <br />T eel <br />12 st <br />orp_O_Box) _____ <br />(Sweet - <br />(City} - _ _ - <br />---- .. ^. - <br />---------- <br />( Owners Si£113rure) <br />(Owners Name - Please Pliny <br />tS <br />(City) - -• -- - - -•- <br />(Street or P.O. Box _ - ... - - - - - - - _.._- - <br />( Owners Signature) <br />(owner's Narne - Please Pnnt) <br />(City) -------------- -- - - - -- <br />(Street or p.O. Box) <br />---- ----... <br />(Owners SIfA31UTC) <br />(Owners Name - Please Print) <br />ttY) ,b <br />