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UNITED STATES <br /> Form 3$30-2 '� ' DEPARTMENT OF THE INTERIOR <br /> (September 2010) BUREAU OF LAND MANAGEMENT FORM APPROVED <br /> MAINTENANCE FEE WAIVER CERTIFICATION OMB NO. 1004-0114 <br /> Expires: August 31,2013 <br /> SEE INSTRUCTIONS ON PAGE 2 <br /> 1. This small miner waiver is filed for the assessment year beginning on September 1,201 and ending on September I, 'Zo I <br /> 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 <br /> United States of America on September 1, Zo 1*7. <br /> 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 <br /> filing this form,an affidavit of assessment work must be recorded by the December 30th following the riling of this waiver. <br /> 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 <br /> 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. <br /> 5.The undersigned understand that mill and tunnel sites may also be listed upon this waiver and be waived from payment of the maintenance fee,and <br /> that a notice of intent to hold for these sites is required to be recorded by the December 301h immediately following the filing of this waiver, <br /> 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 <br /> fraudulent document with the Bureau of Land Management may result in a fine of up to S250,000,a prison term not to exceed five years,or both. <br /> 7•The mining claims mill or tunnel sites for which this waiver from payment of the maintenance fees is requested are: <br /> CLAIM OR SITE NAME BLM RECORDATION SERIAL NUMBS <br /> I LGGkLAAh0 Alle t . - �2 AIM CM C- -2 -7 �3 17 4 I� f t't <br /> 2. 7t / 7 I a? <br /> 4. <br /> 5. <br /> 6. "MubUPDATED <br /> 7. 896 635 <br /> 8. 82 <br /> 9. For AOSE same,it Yr <br /> 10. Rcpt# <br /> Liam <br /> 1/ <br /> The owner(s)(claimants)of the above mining claims and sites are: <br /> OTT C--L-r- w. C_A`D EYL , <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> 40'Z C (vim' 67RE� " <br /> (Street or P.O.Box) <br /> v+rn' <br /> (City) (State) (Zip Code) <br /> (Owner's Name-Please Print) (Owner's Signature) <br /> (Street or P.O.Box) RECORDS UPDATED <br /> 96 635 <br /> Y7 <br /> (City) (State) (Zip Code) - --483 682 <br /> ... .. __..__ .. ._ - 48 . . . .. - -481 <br /> (Owner's Name-Please Print) ! �W� <br /> RCpt r <br /> InitialsDate <br /> (Street or P.O.Box) n <br /> (City) (State) (Zip Code) �pIEIIII+��IIII�I�III�IIIII <br /> (Continued on page 2) 359765 10/4/2012 2:55 PM u Patricia Berger <br /> 3 of 9 \ID R$51.50 D$0,00 Lake County Recorder <br />