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Form 3330-5 <br /> (June-'01_') UNITED STATES <br /> DEPARTMENT OF THE INTERIOR <br /> BUREAU OF LAND MANAGEMENT <br /> MAINTENANCE FEE PAYMENT FORM FOR <br /> LODE CLAIMS, MILL SITES, AND TUNNEL SITES <br /> Remitter Name: E <t G(i c t .ri t ; c' <br /> Mailing Address: I C Lj C) <br /> T <br /> City, State,Zip: `_� ' t l Yl�) L L i 4 � 7 <br /> ❑Check here if this is a change of address. <br /> FOR COUNTY RECORDER'S USE <br /> No. of claims/sites <br /> x$140 per claim/site <br /> Total due BLM $ - `- 1 <br /> 1. The maintenance fee may be paid by cash, check, money order, Bureau of Land Management (BLM) Declining <br /> Deposit Account, or credit card(VISA, American Express, Discover, or MasterCard). Payments must be remitted <br /> to the BLM State Office where your claim or site is recorded and received on or before September 1. If the <br /> payment is mailed, the envelope must be postmarked by a bona fide delivery service on or before September 1 <br /> and received at the proper BLM State Office within 15 calendar days after the due date. Payments may also be <br /> made by telephone using a credit card. A complete listing of BLM State Offices with their addresses and phone <br /> numbers can be found at hnp://www.blin.gov. <br /> 2. The maintenance fee for the following claim(s)/site(s)applies to the assessment year A I <br /> CLAIM/SITE NAME BLM SERIAL NO. <br /> c I I :tC t-� ) ,Ii 1 <br /> Use a separate sheet for additional claim/site names, serial numbers,and claimant names and addresses. <br /> J <br /> t <br /> ' � 1 <br /> IConunued on p�ze?) <br />