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Ministry ofNorthern Developmentand Mines
Ontario
Report of Work Conducted After Recording Claim
Mining Act
DOCUMENT NO.
Personal information collected on this form is obtained under the authorty rf ttwMMi* Act. Trfe information will be used for c^^ this collection should be directed to the Provincial Manager. Mining Lands. M'-1—*- Sudbury. Ontario. P3E 6A5. telephone (705) 670-7264.
Instructions:: and Regulations for- Refer to the Mining
Recorder.- A separate copy of this form must be compkK.. 4?CO?.- Technical reports and maps must accompany this form in duplicate.
900
r VWork Performed (Check One Work Group Only)
Work Group
Geotechnical Survey
Physical Work, Including Drilling
Rehabilitation
Other Authorized Work
Assays
Assignment from Reserve
Type
Pea)*** Stve.'pi"*;^ "ttf^A/cAiA/*? ftfl^'/e Z.' X/^. 5*^a4a p
Total Assessment Work Claimed on the Attached Statement of Costs . QONote: The Minister may reject for assessment work credit all or part of the assessment work submitted if the recorded
holder cannot verify expenditures claimed in the statement of costs within 30 days of a request for verification.
Persons and Survey Company Who Performed the Work (Give Name and Address of Author of Report)Name Address
9- fi S tk-
?(rrri/S
(attach a schedule H necessary)
Certification of Beneficial Interest * See Note No. 1 on reverse sidel certify that at the time the work was performed, the claims covered in this work report were recorded in the current holder's name or held under a beneficial interest by the current recorded holder.
Date Recorded Houer or Agent (Signature)
Certification of Work Reportl certify that l have a personal knowledge of the facts set forth in this Work report, having performed the work or wttnesaed same during and/or after its completion and annexed report Is true.
Name and Address of Person Certifying
For Office Use OnlyTotal Value Cr. Recorded
Date Notice for Amendments Sent
5*QZII W Q
J o -oli-
Total Value W Done
1
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Credits you are claiming in this report may be cut back. In order to minimize the adverse effects of such deletions, please indicate from which claims you wish to priorize the deletion of credits. Please mark (^) one of the following:1. G Credits are to be cut back starting with the claim listed last, working backwards.2. tfi"Credits are to be cut back equally over all claims contained in this report of work.3. D Credits are to be cut back as priorized on the attached appendix.
In the event that you have not specified your choice of priority, option one will be implemented.
Note 1: Examples of beneficial interest are unrecorded transfers, option agreements, memorandum of agreements, etc., with respect to the mining claims.
Note 2: If work has been performed on patented or leased land, please complete the following:
l certify that the recorded holder had a beneficial interest in the patented or leased land at the time the work was performed.
Signature Date
DOCUMENT Na W9650
NOTES•5
LEGUERRIER TP M.I585 HIGHWAY AND ROWTE No.
OTHER ROADS
TRAILS
SURVEYED UNESTOWNSHIPS,, BASE LINES,.ETC. ;
' Surfoce Right* ^servotijon oifoun4 the shores of 011 lake! and rivers
.:( , LO1JS, MINING CLAJMf, PARCELS, ETC
S UNSURVEYED LINES " LOT LINtfS PARCEL, -BOUNDARY
RAILWAY AND RIGHT OF WAY
UTILITY LINES
NON-PERENNIAL SfREAM
f LOOPING OR FLOODING RIGHTSSUBDIVISION
ORIGINAL SHQRELINt
MAKSH OR MUSKEG "
VINES
A^ '
U
DISPOSITION OF CROWN LANDS
PATE.NT, S'lRFACE ft MINING RIGHTS
SURFACE RIGHTS ONLY
MINING RIGHTS ONLY
LEASE, SURFACE a MINING RIGHTS SURFACE RIGHTS ONLY MINING RIGHTS ONLY
LICENCE OF "OCCUPATIONCROWN LAND SALEORDER-IN-COUNCILRESERVATIONCANCELLED
\qsa 3 61 V - .: .l'*— — - u. i CiOIOTi l SSM l SSM
39677 .53917!
SCALE 1 l INCH - 40 CHAINS\59I(T8 i 7/591169
4?6iJ30 l j 9 i l f 8"f, NOTES
i MMMO dbrrs (wePH
AM
*wsrrci*(w 14;** r ! ! t Kte our.iS
TOWNSHIP
JACOSON(Former TP 48)
DISTRICTALGOMA ;.
MINING DIVISION
SAULT STE MARIE
ATE OF ISSUE
ON THIS MAP
VARIOUS SOURCES AND ACCURACY
SHOULD vu^. !f, t THE MINING .
OFONTARIO
MATURA t RESOURCES:\. .- . ...- ,v.-., . . .^ B RANCfHBiO TRA ' * ". i.
M. 1583WHITNEY BLOCK OUEFNS PARK, TORONTO
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