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't :I <br />~. <br />~( 4 <br />i ,- <br />I !. ui~ <br />r:~ <br />`I <br />is <br />r <br /> <br />UL:Yi' <br /> <br />Chnmeter and value of ore _ _ _ _ _ _ _ _ _ _ _ _ _ <br />--------------------- <br />... <br />Nnme of mill (if nny~, ehameter and enpncitp _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />----------------------------------- <br />-------------------------------- <br />Chametor of enrfaco improvements _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ <br />---------------------------------------- <br />Amount and chnmeter of nnder•ground docelopment_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />---------------------------------- ------ <br />------------------------------------------------- <br />------------------------------------------------- <br />Signed _ /_V_ <br />