REV95425

• Permit No: M1985029
• IBM Index Class Name: Revision
• Doc Date: 7/25/1994
• Type & Sequence: AM3
• Media Type: D
• Archive: No

c ~ Mine Safety and Health Administrati~n ~~~
Section I-Violation Data
1 Date Mo Da
oso z Vr
9 0 2. Time 124 Hr Clockl
~
/
/
D 3 Citation
Drder
Number
3630827
Served o ~ r 5. ator
r
/
6. Min .~~ 7. Mine ID
S
~
Z
IContractorl
8. Condition or Practice a. Written Notice (10391 ^
' Q~

CLO

/977 a. '

~-v r
~i4

See Continuation F rm IMSHA Form 70003x1 ^
9. Violation A. Health
Other ~ B. Section
of Act
~ _
~ C. Part/Segion of
Title 30 CFR
8
~
J
a'
Section 11-Inspector's Evaluation
10. Gravity.
A. Injury or Illness (has) list: No Likelihood^ Unlikely Reasonably Likely^ Highly Likely ^
Occurred ^
B. Injury or Illness could rea-
sonably be expected to be: No Lost Worktlays^ Lost Worktlays or Restricted Duty^ Permanently
isabling^ Fatal
C. Signifinant and Substantial (See Reverse): Ves No ^ D. Number o Persons AffeMed D
11. Negligence (check one)
A. None ^ B. Low ^ C Motlerate ^ D. High
E. Reckless Disregard ^
12. Type of Action
_
D
-
/
' 13. Type of Issuance (check one)
Citation ^ Order
Safeguard ^
14. Initial Action
D. Written
A. Citation^ B. Order^ C. Safeguard ^ Notice ^ E Citation/
Order
Number F. D ted Mo Da Vr
15. Area or E uipment
1 I

16. Termination Due
A. Date Mo Da ~'r B. Time 124
Hr. Clockl
Section III-Termination Action
17 Action to Terminate

18. Terminatetl Mo
A. Date Da Vr
R. Time (24 Hr. Clockl
Section IV-Automated System Date
19. Type of Inspection
(activity code) O O / 20. Event Number
o 3 ~ ~ / 21. Primary or Mill
22. Si9natur ~ 23 AR umber
MSHA Form 70003. Mar 85 IRevisedl \ ~