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C PERIODIC INSPECTION FORM Nater, Sedi~ent, or Slurry Iapoundments INSPECTOR'S NAME: N.P.D.E.S. I.D. NO.: FACILITY CONFIGURATION: SITE NAME: MINE NAME: MINE I.D. NO.: DATE: DATE LAST INSPECTION: LOCATION: LOCATION: OWNER'S REP.: Circle ar trite in appropriate response 1. Foundation preparation (removal of vegetation, stumps, topsoil?) 2. Lift thickness (inches) _ 3. Compaction according to approved plan 4. Burning (specify extent and location) 5. Angle of slope (degrees) 6. *Seepage (specify location, color, and approximate volume) From underdrain pipes At isolated points on embankment s opes At natural hillside Over widespread areas From downstream foundation area "Boils" beneath stream or ponde water 7. Cracks or scarps on crest 8. Cracks or scarps on slope 9. Sloughing or bulging on slope 10. *Major erosion problems 11. Surface movements in valley bottom or on hillside 12. *Erosion of toe 13. *Water impounded against toe 14. Existing embankment freeboard (feet) 15. Increase Decrease in water level (feet) 16. Cracks, bulging, or erosion on upstream face 17. Visible sumps or sinkholes in slurry surface 18. *Clogging Spillway channels and pipes Decant system Diversion ditc es 19. *Cracking or crushing of pipes Spillway pipes Decant system 20. Trash racks clear and in place Yes No _ inches Yes No Yes No degrees Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No feet feet Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No *Major adverse changes in these items could cause instability and should be reported to the Engineering Manager and Mine Superintendent for further evaluation. Adverse condi- tions noted in these items should normally be described (extent, location, volume, etc.) in the space on the back of this sheet.