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Form 3830 -2 UNITED STATES
(January 2000) DEPARTMENT OF THE INTERIOR
OS
iromauREAu OF LAND MANAGEMENT
MAINTENANCE FEE WAIVER CERTIFICATION
1. This small miner waiver is filed for the assessment year beginning at noon on September 1, acznand ending at noon on September 1, 2 /4 0.(
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 United
States of America on September 1, acap
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
filing this form; an affidavit of assessment work must be recorded by the December 30th following the filing of this waiver.
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 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.
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 that
a notice of intent to hold for these sites is required to be recorded by the December 30th immediately following the filing of this waiver.
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
fraudulent document with the Bureau of Land Management may result in a fine of up to $250,000, a prison term not to exceed five years, or both.
7. The mining claims, mill or tunnel sites for which this waiver from_payment of the maintenance fees is requested are:
C(1 M 13eK J AID GA/ Ne P_
2.
3.
4.
5.
6.
7.
8.
9.
10.
The owner(s) (claimants) of the above mining claims and sites are:
&e H
(Owner's Name Please Print)
q /4' 4/1914
(Street or P.O. Box)
/4m/b ied l�
(City)
(City)
(Continued on reverse)
SEE INSTRUCTIONS ON REVERSE
X t-f ottnkcc
(City) (State)
k 1110 F 5' S
(Street or P.O. Box)
1
(Owner's Name Please Print)
CLAIM OR SITE NAME
>K �rir�,ti p C:\NCAVWCtir
(Owner's Name Please Print)
(Street or P.O. Box)
(State) (Zip Code)
C/ o0
(Owner's Signature)
/J
002
FORM APPROVED
OMB NO. 1004 -0114
Expires: December 31, 2002
BLM RECORDATION SERIAL NUMBER
S
(Owner's Signature)
(Owner's Signature)
.Ave/. -6_/1
OS6 x782
CUMBERLAND GAP HEARTHSTONE ASSOC. PLACER
DISCOVERY AUGUST 7. 1986
LOCATERS
LEE J CHALLINOR
BRIAN DEAN CHALLINOR
4 PLACER CLAIMS CONTAINING AN AREA OF 80 ACRES
CLAIM DISCRIPTIONS
W2 SW4 NE4
E2 NE4 SW4
W2 N694 SE4
E2 SE4 SW4
T 19 R 116 SEC. 20 LINCOLN COUNTY WYOMING
004