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<br />• iii iiui~iiiiiii~ii <br />110 and 111 Enclosure <br />C~ <br />Permittee Name: <br />Permit No: Darryl D Stout <br />Operation Name: M-79-103- <br />Anniversary Date: AMICK <br />04/08/86 <br />~~ ~~~~ <br />Please complete the following and return this form with your fees and <br />reclamation data. `SUN ~ 1 <br />Enclosed are: (Check space(s) below) ~'^.'lu,,.~C~4~,~~~f-~I~~ArQ <br />~,i~~ ~ ~ <br />~_ Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br />• ,~) iC/O ~~-,~,d ~ ~ Any f , •c ~ ~/4-f,Q~ !~ G~ ~ Af/•~o iFed i.y /~iJ',G <br />C~ if/rl ~L,9-,.id ~.u~,~-S i~~ o~.4~r/ ~ed ..~ /9,~ <br />'1 <br />ea,~a sJsawo <br />S• t9 •Yb <br />Signature ~ ((rr~~ <br />• ~~ ~~ <br />r <br />