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InSUdCt can/nrvesuya uUn uata ~u~~n~~dl~ ~.o. ueNar .u latr...r <br />Meal/Nonmetal Mine Safety and Health <br />Address <br />Closeout ^ Change ^ Delete ^ Event (JUmber 3 4 3 414 <br />Mine lD ~S Q Z /~ p~ ~y <br />0~'G ~'~~ ~r e~P~R <br />Y ~Mr V / umber !~ 9r <br /> ~f Code ~ ~ 5(, z <br />Name of Operator Name of Mine or Mill <br />Type of Inspegion/Investigation <br />i <br />i <br />( Q <br />[ <br />~ <br />L <br />act <br />v <br />ty code) Part 50 Reporting erified <br />~ <br />• <br /> 2. <br />Were Citations/Orders Issued, ', 9. ~ d9 <br />Modified, or Extended? ~ <br />t q~ <br /> Month Day Vear Mon h ay Vear <br />Inspection/Investigation Start Date © Q z ~ Q Inspection/Investigation Stop Date Q Q 3 9 <br />Health Samples: <br /> Personal Exposure Area <br /> Number of Employees Num er of Samples <br />Respirahle Dust <br />Isilira/nuisance) ~ <br />' Vacuum Bottles/Bistables <br />Total Dust <br />(silica/nuisance) I~ Radon Daughters <br />Total Dust <br />(element <br />)l ~ Fibers <br />a <br /> <br />Weltling Fumes ~ Charcoal Tubes <br /> <br />Fibers ~ Detector Tubes <br /> <br />Noise Dosimeter ~ Sountl Level Meter <br /> <br />Charcoal Tubes ~ Dust <br /> <br />Detector Tubes ~ Wipe <br />Sound Level Meter ~ Other. N.E.C. <br />Other, N.E.C. <br />I <br />Miner's Representative Name <br />v.~r~ <br />Telephone Number (include Area C <br />D~~ <br />Person Comp ti g Form <br />NSHA Form 4000-00, Oct 86 IRevi <br />K~ <br />s/~V9d <br />r`nOV 1 I ~,tI NIF ell F <br />