2017-10-11_PERMIT FILE - M2017012

• Permit No: M2017012
• IBM Index Class Name: PERMIT FILE
• Doc Date: 10/11/2017
• Doc Name: Special Use Permit Application
• From: Amazonite Mining, LLC
• To: DRMS
• Email Name: ERR
• Email Name: WHE
• Media Type: D
• Archive: No

UNITED STATES
Form 3830-2 DEPARTMENT OF THE INTERIOR
(January 2017) BUREAU OF LAND MANAGEMENT FORM APPROVED
MAINTENANCE FEE WAIVER CERTIFICATION OMB NO.1004-0119
Expires: January 31,2020
SEE INSTRUCTIONS ON PAGE 2
1. This small miner waiver is filed for the assessment year beginning on September 1, 2017 and ending on September 1, 2018
2. The undersigned and all related parties owned ten or fewer mining claims,mill,or tunnel sites located and maintained on Federal lands in the United States
of America on September I,2017
3. The undersigned have performed the assessment work required by law for each mining claim listed prior to filing this waiver and understand that by filing this form,
the undersigned must file an affidavit of assessment work with the Bureau of Land Management(BLM)by the December 30th following the filing of this waiver.
4. The undersigned understand that if the assessment work obligation has not yet come due under 30 U.S.C.28(for those claims in their first assessment year only),
a notice of intent to hold reciting this condition must be recorded by the December 30th following the filing of this waiver.
S. The undersigned understand that mill and tunnel sites may also be listed on this waiver and be waived from payment of the maintenance fee,and that a notice of
intent to hold for these sites is required to be filed with the BLM by the December 30th following the filing of this waiver.
6. The undersigned understand and acknowledge that pursuant to 43 U.S.C.1212 and 18 U.S.C_1001,the filing or recording of a false,fictitious,or fraudulent
document with the BLM may result in a fine of up to-S250,000,a prison term not to exceed five years,or both.
7. The mining claims,mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are:
CLAIM OR SITE NAME BLM RECORDATION SERIAL NUMBER
1- ,jZ-u t7 f N 1 L.o rA t.l ' ( a SS"3 5-
2. S•rabEofI- LoPtra 44- a- alSS3 s—
Lte
0
3. RaFF -64401 I a 7Zz(t-
4. rAtCk- 1MQN f...0 PE
5. t J
NNS C.)rz'c.
6. -w., n tt:
7. .Get
8. 1 ,.:c-{
9.
nr
:, _
0.
The owner(s)(claimants)of the above mining claims and sites am: -�
ReTS't 1' Ft)r2lQCST- /. .5a
(Owner's Name-Please Print) (Owner's Signature)
OS 1 S, Ate lernETO PEAK K J.., (TrL.EYONI CO S'OL 7
(Owner's Mailing Address) (City) (State) (Zip Code)
TE FF '1 6. FO RE"-- ,44t-r
(Owner's Name-Please Print) (Owner's )
' 'O 'i 5• VEr,rNEid PEAK. J+(TTLElo'► ea 7017
(Owner's Mailing Address) (City) (State) (Zip Code)
(Owner's Name-Please Print) (Owner's Signature)
(Owner's Mailing Address) (City) (State) (Zip Code)
(Owner's Name-Please Print) (Owner's Signature)
(Owner's Mailing Address) (City) (State) (Zip Code)
(Continued on page 2)