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• Mlne Safety and Healih ~inisiratlc~n ~ \~~ <br />Section I-Volation <br />1. Date Mo <br />p Da <br />o 2 Yr <br />9 0 2 Time 124 Hr Clockl <br />/ <br />D <br />3 <br />0 3 Citation <br />Ortler <br />Number <br />3630824 <br />. Serve Tp~~ ,r i s <br />RR~~JJ'' ...~//Jl.le,//p/JQ~ 5. ator <br />6. Mine <br />~ ~ 7. Mine ID <br />S <br />O <br />~ <br />7 <br />IConiractor) <br />a. Condition or Practice <br />Ba Wnnen Nonce 110391 ~ <br />7 Q ~Z <br /> <br />/ySff r <br /> <br />9 0 ' <br /> <br />' /s /9 90, <br /> <br /> <br /> <br /> <br /> <br />See Continuation F rm (MSHA Form 700O3a1 <br />9. Violation A Health <br />Other lJ B. Section <br />of Att <br />p <br />3 _ C. Part/Section of <br />Title 30 CFR <br />S <br />~ <br />• <br />3 <br />D <br />CL- <br />Section II-Inspector's Evaluation <br />10. Gravity: <br />A. Injury or Illness Ihasl list: No Likelihood Unlikely ^ Reasonably Likely^ Highly Likely^ <br />Occurred ^ <br />B. Injury or Illness could rea- <br />sonably be expected to be: No Lost Work tlays Lost Workdays or Restricted Duty^ Permanently <br />DisabGng^ Fatal ^ <br />C. Significant and Substantial (See Reversal: Ves ^ No O Number o Persons Affected Q Q <br />11. Negligence (check one) <br />A. None ^ B. Low ^ C Moderate D. High ^ <br />CCC""" <br />E Reckless Disregard ^ <br />12. Type of Action <br />/ <br />O <br />- <br />' 13. Type of Issuance ccheck one) <br />Citation Order^ ' <br />Safeguard ^ <br />14. Initial Action <br />D. Written <br />A. Citation ^ 8. Order ^ C. Safeguard ^ Notice ^ E. Citation/ <br />Order <br />Number F. atetl Mo Da Yr <br />15. Area or Equipment <br /> <br /> <br />16. Termination Due <br />A. Date Mo <br />Q S Da <br />/ ~ qVr <br />/ ~ B Time 124 <br />Hr. Clockl <br />Q <br />Q <br />Section III-Termination Action <br />17. Action to Terminate <br /> <br /> <br /> <br />1a. Terminated Mo Da Vr <br />A. Date <br />B. Time (24 Hr. Clockl <br />Section IV-Automated System Data <br />19. Type of Inspection <br />(activity code <br />Q <br />/ 20. Event Number <br />Q <br />3 <br />4- <br />-~ 21 Primary or M~II <br />22 Sig 23 4R Number <br />MSHA Form 7000-3, Mar 85 ;Revis$11 I I ( 1 <br />\1 J <br />