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Tl a Paperwork Reduction Act of 1995 (44 U.S.C. 350], et seq.) requires us to inform you that: <br />This information is being collected to authorize and evaluate proposed exploration and mining operations on public lands. <br />Response to the provisions of this lease form is mandatory for the types of activities specified. <br />BLM would like you to know that you do not have to respond to this or any other Federal agency-sponsored information collection unless it <br />displays a currently valid OMB control number. <br />BURDEN HOURS STATEMENT <br />Public reporting burden for this form is one hour. This Includes reading the instructions and provisions, completing and signing [he lease <br />form to BLM. Direct comments regarding the burden estimate or any other aspect of this form [o: U.S. Department of the Interior, Bureau <br />of Land Management, Information Clearance Officer (WO-630), Mail Stop 40] LS, Washington, D.C. 20240, and the Office of <br />Management and Budget, Office of Information and Regulatory Affairs, Interior Desk Officer (1004-0073), Washington, D.C. 20503. <br />THE UNITED STATES OF AMERICA <br />Company or Lessee Name eG~ <br />store of Lessee) <br />C- rG~Gf.f~2~ <br />(Title) <br />~~~~~~~~ ~~~ f <br />~ mate) <br />Title 18 U.S.C. Section 1001, makes it a crime for any person knowingly and willfully to make to any department or agency of the United States any <br />false, ftctitious or fraudulent statements or representations as to any matter within its jurisdiction. <br />trU.S. GOVERNMENT PRINTING OFFICE: 199944-505 <br />® PriW m Bt,dy ~~p <br />r~t <br />_~ <br />- _ (_) <br />j; j <br />L "l <br />J <br />II <br />CJ <br />