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RECEIVE® <br /> . _ N O V 2 9 Page 1 of 2 Pages <br /> United States Department of the Intenp&Dept of N tura IResoji cON l s Office Use Only <br /> Office of Surface Mining 1a 1b 1c <br /> Mine Site Evaluation Inspection Report [Ufl M Ffl <br /> Y Y M M Batch Report <br /> 10. Date of Inspection <br /> 2. Name of Permittee 9. MSHA Number (Y Y M M D D) <br /> 3.Street Address 11.State Permit Number <br /> 4.City 5.State 12. Name of Mine <br /> FT I I I, � d I I I I I I m L- 1; � -� I I - I I I I I 1 1 <br /> 6.Zip Code 7.Area Code 8.Telephone Number 13.County Code 14.State Code 15.Strata 16.State Area Office <br /> 111111 FM H- 1- �—HJddjlll <br /> IE I[] Ell <br /> 17.OSM Field 18.OSM Area 19.OSM 20.Type of Inspection 21.Joint Inspection 22. Inspector's ID <br /> Office No. Office No. Sample No. (Code) Yes No No. <br /> m Id I I � I D H n <br /> 23.Status 24.Type of Activity(check applicable boxes). <br /> A Type of Permit <br /> A � Steep Slope E F] Anthracite <br /> B Mine Status(Code) <br /> B Mountain Top Removal F Federal Lands <br /> C m Type of Facility(Code) <br /> C � Prime Farmlands G � Indian Lands <br /> D • Number of Permitted Acres ❑ <br /> D Alluvial Valley Floors H Other <br /> E • Number of Disturbed Acres <br /> 25. Performance Standards(Codes) <br /> Instructions: Indicate compliance code. For any standard marked 2 or 3 provide narrative to support this determination. <br /> Standards That Limit the Effects to the Permit Area Standards That Assure Reclamation Quality and Timeliness <br /> A ❑ Distance Prohibitions M Topsoil Handling <br /> B a Mining Within Permit Boundaries N Backfilling and Grading <br /> C Signs and Markers O Following Reclamation Schedule <br /> D Sediment Control Measures P El Revegetation Requirements <br /> E ❑ Design and Certification Requirements— Q E] Disposal of Excess Spoil <br /> Sediment Control <br /> R [] Handling of Acid or Toxic Materials <br /> F F Effluent Limits <br /> S E] Highwall Elimination <br /> G F-1 Surface Water Monitoring <br /> T Downsiope Spoil Disposal <br /> H F] Ground Water Monitoring <br /> U E] Post Mining Land Use <br /> I a Blasting Procedures <br /> V � Cessation of Operations:Temporary <br /> J � Haul/Access Road Design and Maintenance _ <br /> W � Other <br /> K � Refuse Impoundments <br /> L ❑ Other: Specify <br /> Distribution:Original-Field Office,Green-Headquarters, Blue-State's Copy,Yellow-Inspector's Copy, Pink-File Copy IE-163(1/83) <br />