Chapter X: Appendix

Form 3400–6 UNITED STATES | FORM APPROVED
(October 1968) DEPARTMENT OF THE INTERIOR | BUDGET BUREAU NO. 42–R1373.1
BUREAU OF LAND MANAGEMENT |_____________________________
|
| Date
|_____________________________
APPLICATION FOR SURVEY OF MINING CLAIM |
| SEE INSTRUCTIONS ON REVERSE
_____________________________________________|_____________________________
|
1. Name of Applicant | Address (_include zip code_)
(_first, middle initial, last_)|
|
____________________________________|______________________________________

Hereby makes application for an official mineral survey of the mining
claims named and identified in this application
___________________________________________________________________________

2. Give group name (_if any_)
___________________________________________________________________________

3. NAME OF CLAIM(S)
___________________________________________________________________________
|
| DATE
|_________________________________________
| | | |
NAME OF LOCATION | LOCATED | RECORDED | AMENDED | AMENDED
| | | | RECORDING
_________________________________|_________|__________|_________|__________
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
_________________________________|_________|__________|_________|__________

4. LOCATION OF CLAIM(S)
___________________________________________________________________________
| | |
Section | Township | Range | Meridian
| | |
________|__________|_______|_______________________________________________
| |
County | State | National Forest
| |
___________________|_______|_______________________________________________

5a. Is each claim based on a valid location and fully described in the
certified copy of the record of each location certificate filed with this
__ __
application? |__| Yes |__| No

b. Is each location distinctly marked by monuments on the ground and can
__ __
its boundaries be traced readily? |__| Yes |__| No
___________________________________________________________________________