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Form <br />9. Violation IA Otheer Dn IB o5f Actn I I I I-I I I IC Tt le/30 CIFRot I I ~`I . I / lyl~ ~3I ~j~ <br />Section II-Insyector's Evaluation <br />10. Gravity: <br />A. Injury or Illness (has) (isl: No Likelihood^ Unlikely® Reasonably Likely^ Highly Likely^ Occurred ^ <br />B. Injury or Illness could rea- <br />sonably be expected to be: <br />No Lost Workdays^ <br />Lost Workdays or Restricted Duty ^ <br />Permanently Disabling^ Fatal <br />C. Signifignt and Substantial (See Resersel: Yes ^ No ® D. Number of Persons Affected O O <br />11 . Negligence (check one) <br />A. None ^ B. Low ^ C. Moderate ® D. High ^ E. Reckless Disregard ^ <br />/I I ~ I~ I ~ Citation ® Order ^ Safeguard ^ <br />14. Initial Action U E. Citation/ F. Dated Mo Da Vr <br />D. Written Order I I - <br />A. Citation ^ B. Order ^ C. Safeguard ^ Notice ^ Number <br />15. Area or Equipment <br />lb. lerminauon uue I I O I U I l~ ~9T~r7IB Time 124 I I/ ICI <br />A. Orate Hr. Clock) Cr C <br />xcuon ui-iermmanon r+cuon <br />17. Action to Terminate <br />IA °~te to lU lyl~isl7~6. Time 124 Hr. Clock) I ~/1 ~I`/ <br />Section I V-Automated System Da[a s~JJ ~~ <br />19. Type of InSVeRion 20. Event Number 21. Primary or Mill <br />(activity Code) . n 9 n // l S 7/ 3 QI <br />GO.S.GOVERNMENT PRINTING OFFICE ls1-Ea9~59a <br />Mine Citation/Order • U.S. Department I~ataor /~ <br />e <br />Mine Safety and Hea Administration <br />Section I-Violation ^wm <br />