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Mme 5alely and Healln <br />• Section I-Violatlon Data <br />1 Date Mu Da Yr 2. lime (24 Hr Clockl <br />ohs olz 9101 / ~ <br />-~erved T~ ~ ~ r ~ _ ' .41nA 5. OPe to ~- <br />ID I.,I ~I_ <br />8. Coladition or <br /> <br />mlrnstratjc ~~~ <br /> <br />3. GltatlOq <br />Order <br />Number 3630826 <br />r / ~~ <br /> IComractor) <br />8a. Wntten Notice (103gU rl <br /> <br /> <br />See Continuation F m (MSHA Form 70003x1 ^ <br />9. Violation A. Health g Secyion _ C. Part/Section of <br />Other ~ of Act / ~ ~ Title 30 CFR S ~ 2 Q+ <br />Section II-Inspector's Evaluation <br />10. Gravity: <br />A. Injury or IIIne55 (has) lisl: No Likelihootl^ Unlikely Reasonably Likely[ <br />B. Injury or Illness could rea~ <br />sonablY be enpected to be: No Lost Workdays^ Lost Workdays or Restricted Duty [ <br />C. Significant and Substantial (See Reversal: Yes ~ No ^ <br />11. Negligence (check one) <br />A None ~ 8. Low ~ C Moderate ~ D. High <br />12. Type of Action 13. Type of Issuance <br />' - - Citation <br />14. Initial Action E. Citation/ <br />D Written Order <br />A. Citation B. Ortler~ C. Safeguard ~ Notice ~ Number <br />15. Area or Equipment <br />r <br />ly Likely U Occurretl (J <br />Permanently isabling~ Fatal <br />D Number of arsons Atteaed Q <br />Reckless Disregard <br />me) <br />Jrder~ Safeguard <br />,.,. .~....,,,o.,.,., .,.,~ I I IV I lu I I IB Time 124 <br />A Date <br />Hr. Clock) <br />Section III-Termination Action <br />17. Action to Terminate <br />IA Date I ~ I I I I IB. Time (24 Hr. Clockl <br />Section IV-Automated Svstem Data <br />19 Type of Inspection 20. Event Number 21. Primary or Mill <br />lactivit ode) O o , O ~ 3 , <br />22 ~ a re ~ 23 Aft N tuber <br />MSHA Form 70003, Mar 85 IRevis 1 <br />