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~~ • <br />;... <br />• iii iiiiiiiiiiiuiii <br />Paae , of 7 Papea <br /> ~~ <br />United States Department of th e Interior <br />~~/~ For Offic e Use Only <br />Office of Surtace Mining ///,, <br />Mine Site Evaluation Inspec~.DRepoff~ 27 ~ <br />A <br />9B ,a <br />~ ,D ,~ <br />m m <br />4 <br />ND <br />Cod <br />~ <br /> /1 <br />Q <br />~y <br />~'at a f <br />a ~Mgn Y Y M M Bstcn RapOn <br /> N <br />onr <br /> Ctp66 Oy <br />~ 10. Data or Inspection <br />2. Name of Parmittee B. MSHA Numb6~ (Y Y M M D D) <br /> <br />3. Sirest Address 11. State Permit Number <br /> <br />4. City 5. Stat e 12. Name of Mine <br /> <br /> is <br />8. 21p Cotle 7. Area Code 8. Telephone Number 13. County Cotle 14. State Code 15. Strata 16. State Area Office <br /> <br /> <br />17. OSM Fleltl 18. OSM Area 19. OSM 20. Type of Inspection 21. Joint Inspection 22. InsDector'e ID <br />Office No. Oflice No. Sample No. (Cotle) Yes No No. <br /> <br />23. Statue 24. Type of Activity (check applicable boxes). <br />A ~ Type of Permit <br />A ~ Steep Slope <br />E ~ Anthracite <br />B ~ ,=} ~ Mina Status (Code) <br />B ~ Mountain Top Removal <br />F ~ Federal Cantle <br />C ~ Type of Facility (Cade) <br />C ~ Prime Farmlands <br />G ~ Indian Cantle <br />D ~ '~ C • '~; Number of Permitted Acres <br />D ~ Alluvial Valley Floors <br />H ~ Olhar <br />E ~ 1~ ; ~ ~ • _1 Number of Disturbed Acres <br />25. Performance Stentlards ICodes) <br />Inabuctbnc Intllcate compliance cods. For any stantlard marketl 2 or 3 provide narrative to support this determination. <br />Stantlartle That Limit the Eflects to the Permit Area Standards That Assure Rxlematlon Quality and Timeliness <br />A ~ Distance Prohibitions M a Topsoil Handllnq <br />B ~ Mlnlnq Within Permit Bountlerlea N ~ Backfilllnq antl Gradlnq , <br />C /~ Signs and Markare O ~ Following Reclamation Schedule <br />D ~ Sediment Control Measures P ~ Revegetallon Raqulremanta <br />E ~ Design antl Certllleatlon Requirements- O ~ Disposal of Excess Spoil <br />Sediment Control <br />R ~ Hentllinq of Acld or Tozlc Materials <br />F ~ Effluent Llmlta <br /> <br />G ,~ SuAace Water Monltorinq S © Hlghwall Elimination <br /> T ~ Downelope Spoil Disposal <br />H ~ Grountl Water Monltorinq <br />U ~ Post Mlnlnq Land Use <br />I ~ Bleating Procedures <br /> V ~ Cessation of Operations: Temporary <br />J ~ HaullACCesa Roatl Dealpn and Melntenanca <br />W ~ Other <br />K ~ Refuse Impoundmante <br />L ~ Other. SDeclh/ <br />Distribution: Oriplnal -Field Office, Green - Neadquartera, Blue -State's Copy. Yellow -Inspector's Copy, Pink - Flle Copy IE - 163 (1/83) <br />