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Cripple Creek & Victor Gold Mining Company <br />Valley Leach Facility Work Permit <br />Issued: Date Time <br />Work requested by: <br />Nature of work requested: <br />Work to be performed by: <br />Proximity to Edge of Liner (ft): <br />Proximity to Major Header (ft): <br />Depth to Liner (ft): _ <br />AM/PM Expires: Date Time AM/PM <br />YES NO N/A <br />Is work within 20' of major active header? <br />Is work within 75' of liner edge? Inside and outside? <br />Has necessary plant alarms been engaged, prior to work starting? <br />Has access to work area been described? <br />Do cone lines adequately identify the work, and work area limits? <br />Are the cone line meanings understood? <br />Is there underground utilities in the area? <br />Are there overhead lines in the area) <br />Have all engineered points been put out that need to be put out? <br />Job Specific Instructions/Hazards: <br />Supervisor: Date: <br />Signature <br />Operator: Date: <br />Signature <br />Doc Name: VLF Work Permit Page 1 of 1 July 23, 2008 <br />Doc #: H&S 005-41.1 Printed copies are uncontrolled Revision 1