___________________________________________________________________________ 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.