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Mlne Cltatlon/vrdcr • U.S. L7epartment of L•r <br />Mlne Safety and Health Adminlst <br />Section I <br />~,/ <br />1 Date Mo Da <br />O z Vr <br />90 2 Time 124 Hr Clock) <br />0 <br />93 3 Citation <br />Order <br />Number <br />3630821 <br />erved T r 5. Ope , <br />6. ine 7. Mine ID <br />O <br />~ <br />7 <br />G <br />(Contractor( <br />8. C d' i or Practice 8a. Written Notice 11039) ^ <br /> <br /> <br />r <br /> <br />f <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />See Continuation F rm IMSHA Form 70003x1 ^ <br />9. Violation A. Health <br />Otheer ~ B. Section <br />of Act _ C. Part/Section of <br />Title 30 CFR <br />S / <br />CP <br />~ <br />~ <br />Q <br />Section II-Inspector's Evaluation <br />10. Gravity: <br />A. Injury or Illness (hall list: No Likelihood Unlikely Reasonably Likely Highly Likely <br />Occurretl <br />B. Injury or Illness could rea~ <br />sonably be e><Pected to be: No Lost WorktlaYS Lost Workdays or Restricted Duty^ Permanently <br />~sabling^ Fatal <br />G Significant and Substantial (See Reversal: Vas ^ No D Number o Persons Affected Q Q <br />11 . Negligence (check one( <br />A. None ~ B. Low ~ C. Moderate D. High ~ <br />E Reckless Disregartl <br />12. Type of Action <br />O ,// <br />Y <br />~ 13. Type of luuance Icheck one) <br />Citation Order <br />Safeguard <br />14. Initial Action E. Citation/ <br />D. Written ~ Order <br />A. Citation ~ B. Order ~ C. Safeguard ~ Notice <br />Number F tad Mo Da Yr <br />75. Area or Equipment <br /> <br /> <br />16. Termination Due <br />A Date Mo <br /> <br />o s Da <br /> <br />o z Vr <br /> <br />9 o <br />B. Time 124 <br />Hr. Clock, <br /> <br />0 <br /> <br />9 <br /> <br />3 <br /> <br />5 <br />Section III-Termination Action <br />17 Acti to Terminate <br /> <br /> <br /> <br />18. Terminated <br />A. Date Mo <br />O Da <br />O z Vr <br />~ D <br />B. Time (24 Hr. Clock) <br />D <br />~ <br />? <br />J <br />Section IV-Automated System Data <br />79. Type of Inspection <br />(activi code) <br />D <br />O <br />~ 20. Event Number <br />D <br />~ <br />3 <br />/ 21. Primary or Miil <br />t re ~ n 23 AR umber <br />G95HA Form 70003 Mar 85'~I~evisedl <br />c <br />