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<br />110 and 111 Attachment <br />Permittee Name <br />Operation Name <br />Hendricks Mining Company <br />C fLOy ~ S N ~ N 6- C.o , I.TD , <br />Permit No: 77-410 <br />Anniversary Date: November 3 <br />Please complete the following and return this form with your fees and <br />reclamation data. <br />Enclosed are: (Check box(es)) <br />ICI <br />ICI <br />Remarks: <br />~ r <br />• . w <br />Check or money order payable to Colorado Mined Land <br />Reclamation Division for annual fees due <br />Annual Report <br />