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<br />Ontario <br />Oil, Gas and Salt Resources Acl <br />Ministry of MinislAre des <br />® NaNral Richessas <br />Resources naorrelles <br />ANNUAL REPORT OF GEOPHYSICAL AND GEOCHEMICAL EXPLORATION <br />FOR THE YEAR <br />Form 4 <br />Type of Survey Township Contractor line km kmz <br />Attach a scaled map of lots and concessions showing loption of survey <br />The untlersigned certifies that the inlonnation provided herein is complete and accurate and he/she has auNOrity to bind the <br />operator. <br />OPERATOR <br />ADDRESS <br />SIGNATURE DATE TEL.# <br />r <br />