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AVS Annual Review <br />Inspection Worksheet <br />Date // he // � <br />Mine Name/Permit Number C 'OZ2 <br />Inspector Signature <br />Based on your ON -SITE Observation, please answer the following: <br />1) Mine ID sign <br />2) <br />3) <br />a) Permittee <br />b) Operator U, 1,c a. , s L c <br />RECEIVED <br />NOV 0 8 2013 <br />DIVISION OF RECLAMATION <br />MINING AND SAFETY <br />C) MSHA ID (not required to be on sign) <br />Direct inquiry (of persons on the site) <br />a) Permittee Lubko Ltd- <br />b) Operator <br />C) MSHA ID <br />Is ownership /control information for permittee a d operator noted in field consistent with <br />what is listed in the permit application? Yes A No <br />If No, what is in conflict? <br />DRMS is required to verify this information as specified in the AVS MOU if the permitting action <br />was approved subsequently to the MOU (renewal, transfers and revisions). Annually as long as coal <br />extraction from the site has not been completed, DRMS must determine whether officer /controller <br />information is complete and accurate in AVS. In making the determination of complete and accurate <br />information, on -site observations and direct inquiry of persons on the site is necessary. The information <br />on this form will be verified with AML, MSHA, and EIA information in AVS. Please return the form to <br />Mary Rodriguez to be verified in AVS. <br />