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Mlne Safety and Health A~istratlor~ ~ <<~ <br />Secton <br />1 Dale Mo Da <br />0 0 Vr <br />9 0 2. Time 124 Hr Clockl <br />l <br />~ <br />4 <br />3 Citation/ <br />Ortler <br />Number <br />3 6 3 0 8 3 0 <br />erved T t r 5 Oper r <br />I <br />l <br />6 Min~j ///1 <br />////._ ~ <br />(/ <br />lX <br />~ <br />~ <br />/ 7. Mine ID <br />0 <br />- <br />Z <br />~ <br />IContractorl <br />8. Co <br />n <br />io <br />n or <br />Pract <br />ce 8a. Written Notice 110381 ^ <br />8N <br /> <br />~ ~~ - - <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />See Continuation F m IMSHA Form 7000-3a1 ^ <br />9. Violation A Health ~ <br />Other ~ g_ Secion <br />of Act _ C. Part/Secion of <br />Title 30 CFR <br />~ <br />/ <br />Section II-Inspector's Evaluation <br />10. Gravity. <br />A. Injury or Illness Ihasl list: No Likelihood^ Unlikely Reasonably Likely^ Highly Likely ^ <br />Occurretl ^ <br />8. Injury or Illness could rea- <br />sonably be expected to be: No Lost Worktlavs^ Lost Workdays or Restricted Duty^ Permanently <br />isabling^ Fatal <br />C. Significant and Substantial (See Reversal: Yes ^ No D. Number of arsons Affected Q <br />11. Negligence (check onel <br />A. None ^ B. Low ^ C. Moderate ~ D. High ^ <br />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 />Number F. D fed Mo Da Vr <br />15. Area or Equipment <br /> <br /> <br />16. Termination Due Mo <br />A Date D S Da <br />~ $ Vr <br />9 ~ B. Time 124 <br />Hr. Clockl <br />Q <br />Section 111-Termination Action <br />17. Action to Terminate <br /> <br /> <br /> <br />18. Terminated <br />A. Dale Mo Da Vr <br />B. Time (24 Hr. Clock) <br />Section IV-Automated System Data <br />19. Type of Inspection <br />(activity code) <br />a <br />/ 20. Event Number <br />O <br />~ <br />3 1 <br />/ 21. Primary or Mill <br />22 Si r ~ 23 AR I lumber <br />9 <br /> <br />MSHA Form 7000-3. Mar 85 :Revisetl (` <br />