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• Mlne Safety and Health ~Inlstratitln (/~ `~~ <br />Sec <br />ioianon ua[a <br />1 Uale Mu <br />os Da <br />o 2 Vr <br />90 2 Time (24 Hr Clockl <br />/ <br />l <br />/ 3. Citation <br />Ortler <br />Number <br />3630826 <br /> <br />r <br />~e y~Q/r r 5. OUe to r <br />6 M' a 7. Mine ID <br />O <br />! <br />J <br />O <br />IContragorl <br />6. Co ition or Practice 8 . Written Notice 11039 ^ <br />v <br />r <br />~ <br />1 r <br />~ <br />Q~ /~ <br />S ~[i ~~~ <br /> <br /> <br />r <br /> <br />. r <br /> <br /> <br /> <br />See Continuation F rm IMSHA Form 70003x) ^ <br />9. Violation A. Health ^ <br />Safety ^ <br />Other ^ B. Section <br />of Ac[ <br /> <br />it <br /> <br />/ <br /> <br />S _ <br /> <br />~ C Part/Section of <br /> <br />Title 30 CFR <br /> <br />8 <br /> <br />~ <br /> <br />Z <br /> <br />a+ <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 mould rea~ <br />sonably be expected tp be: No Lost Worktlays^ Lost Worktlays or Restricted Duty^ Permanently <br />isabling^ Fatal <br />C. Signi(iwnt and Substantial (See Reversel: Ves No ^ D. Number o Persons Affected Q <br />11 Negligence (check one) <br />A. None ^ B. Low ^ C. Moderate ^ D. High <br />E Reckless Disregard ^ <br />12. Type of Action <br />~ 13. Type of Issuance (check onel <br />Citation ^ Order <br />Safeguard ^ <br />14. Initial Action <br />D. Written <br />A. Citation ^ B. Order ^ C. Safeguard ^ Notice ^ E Citation/ <br />Order <br /> <br />Number F. D tetl Mo Da Vr <br />15. Area or Equipment <br />1 r <br /> <br />16 Termination Due <br />A Date Mo Da Vr B Time (24 <br />Hr Clockl <br />Section II I-Termination Action <br />17. Action to Terminate <br /> <br /> <br /> <br />18. Terminatetl <br />A. Dale Mo Da Vr <br />B. Time 124 Hr. Clockl <br />~ <br />Section IV-Automatetl System Data <br />19. Type of Inspection <br />(activity ode) <br />O <br />O <br />/ 20. Event Number <br />O q <br />J <br />3 21. Primary or Mill <br />2.' a re ~r 23 AR <br />r umber 9 <br />i <br /> <br />n'ianr, rune ruuu-o, mar ao irtevisqul <br />