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<br />d ~d ~ cL i4 ~~~ b, ~ ; SIII III I II I II IIII III <br />j'h, h d ~ ~ <br />110 and 111 Enclosure <br />Permittee Name: <br />Permit No:. Darryl D Stout <br />N 79 103 <br />~~ ; <br />Operation ame. M- - - MAY 1 9 <br />Anniversary Date: AMICK 1986 <br />04 / 08 ! 86 l4fl~~~ I. <br />Please complete the following and return this form with your fees and ~ Resa~;~~;~ <br />reclamation data. <br />Enclosed are: (Check space(s) below) <br />Check or money order payable to Colorado Mined Land Reclamation <br />Division for annual fees due <br />Annual Report <br />Remarks: <br />S/~5/~~ <br />~~ <br />