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THE UNITED STATEa DF AMERICA <br />9 <br />/J l .; t <br />• pany or Lesse~e/NJar/~' / <br />~,l <br />~~Ga.d..~ /1 <br />~ ~ (S~~e of Lessee) <br />.. (Title) <br />' (Date) <br /> <br />3ames E. Edwards, Jr. <br />(Signing Officer) <br />Chief, Branch of Solid Minerals <br />(Tile) <br />/® 30 ~~- <br />(Date) <br />Title 18 U.S.C. Section 1001, makes it a crime for any perpon knowingly and willfully to make to any department or agency of the United States any <br />false, fictitious or fraudulent statements or representations as to any matter within its jurisdiction. <br />This form does not constitute nn information collection as defined by 49 U.S.C. 3502 and therefore does not require OMB approval. <br />Kz LL.S.GOVERNMENT PRINTING OFFICE:1995-674-732 - ~ _ <br />~i <br />~ '=~ <br /> <br />i <br />- 1 J <br /> <br />' t ~-.. <br /> <br /> ~.l ~ .. <br /> .~ <br />~.~ <br />~ <br /> <br /> V\ <br /> I~.i <br /> <br />