Chapter XIV: Appendix: #4

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Form 3860–7 UNITED STATES
(November 1976) DEPARTMENT OF THE INTERIOR
(formerly 3400–8) BUREAU OF LAND MANAGEMENT

CERTIFICATE OF SURVEYOR

___________________________________________________________________________
Name of Mineral Surveyor | Date
|
____________________________________________________|______________________

I HEREBY CERTIFY That in pursuance of an order received from the

, at

dated ,19 , I have carefully executed the survey of

the claim of

known as the (_lode, placer, or mill site_)

situated in , Township ,

Range , Meridian, in the State of .

This survey, designated as number , has been executed by me and under
my direction and has been made in strict conformity with said order, the
Manual of Instructions for the Survey of Public Lands of the United States,
and in specific manner described in the foregoing field notes.

I FURTHER CERTIFY That the labor expended and improvements made
upon and for the benefit of the

(_lode or placer_) location(s)
embraced in the said mining claim by claimant(s) or

grantors are fully stated in my report. The character, extent, location,
and itemized value are specified in full detail. No portion of, or interest
in, said labor and improvements so credited to this claim has been included
in the estimate of expenditures upon any other claim.

____________________________________ _____________________________________

(Location) (Signature of Mineral Surveyor)
___________________________________________________________________________

CERTIFICATE OF APPROVAL

| Office
|
|_________________________
| Location
|
|_________________________
| Date
|
|_________________________

The foregoing field notes of mineral survey number , in
__ __
, |__| surveyed|__| unsurveyed

Township , Range ,

Meridian, in the State of ,

executed by , Mineral Surveyor,

under order dated , 19 , having been critically examined
and the necessary corrections made prior to their certification by the
surveyor, the field notes and the survey therein described are hereby
approved.

____________________________________ _____________________________________

(Authorized Signature) (Title)

CERTIFICATE OF TRANSCRIPT

I HEREBY CERTIFY That the foregoing transcript of field notes of

the above-described mineral survey number is a true copy of the
original field notes.

____________________________________ _____________________________________

(Authorized Signature) (Title)
___________________________________________________________________________

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
false, fictitious, or fraudulent statements or representations as to any
matter within its jurisdiction.
___________________________________________________________________________