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Page 2 of 2 Pages <br /> . • United States Department of the Interior <br /> Office of Surface Mining <br /> Mine Site Evaluation Inspection Report <br /> 2&State Permit Number 27. Date of Inspection <br /> (YYMMDD) <br /> 28. Yes No Do mining and reclamation activities on the site comply with the plans in the permit? <br /> ❑ ❑ If no,provide narrative to support this determination. <br /> 20. Indicate number of complete and partial inspections conducted by the State to date for this annual review period: <br /> 29a. ❑ Number of Completes 29b. ❑ Number of Partials <br /> 30.Indicate number of complete and partial inspections required by the State during this annual review period: <br /> 30a. ❑ Number of Completes 30b. ❑ Number of Partials <br /> 31.Has inspection frequency been met? <br /> Yes No Yes No <br /> 31a. D ❑ Completes 31b. ❑ ❑ Partials <br /> 32. FEDERAL ENFORCEMENT INFORMATION. [Enter violation number. Check appropriate box(es)] <br /> Ten-Day Notice No. Notice of Violation No. Cessation Order No. Violation Codes <br /> A❑ ❑ ❑ Authorizations to Operate <br /> B ❑ ❑ Signs and Markers <br /> C❑ ❑ ❑ Backfilling and Grading <br /> ..................... ........ ................ <br /> D❑ ❑ ❑ Highwall Elimination <br /> ..................... ........................ <br /> E❑ ........... ❑ ❑ ........................ Rills and Gullies <br /> F❑ ❑ Improper Fills <br /> ..................... ..................... <br /> G❑ ❑ ❑ Topsoil Handling <br /> ..................... ..... ................... <br /> H❑ ❑ ❑ Sediment Ponds <br /> ❑ ❑ ❑ Effluent Limits <br /> ..................... ... ..................... <br /> J El ❑ Water Monitoring <br /> K❑ ❑ ❑ Buffer Zones <br /> L❑ ................... ❑ ..................... ❑ ............... ... ...... Roads <br /> M❑ ..................... ❑ ..................... ❑ .................. ...... Dams <br /> N❑ ..................... ❑ ❑ Blasting <br /> ..................... ............. ..... .. .... <br /> O❑ ❑ ❑ ... ............ . .. .... .. Revegetation <br /> P❑ ❑ ❑ Spoil on the Downslope <br /> p❑ ❑ ❑ Mining Without Permit <br /> ..................... ..................... <br /> R❑ ❑ ❑ Exceeding Permit Limits <br /> S❑ ❑ ❑ Distance Prohibitions <br /> T❑ ❑ ❑ Toxic Materials <br /> U ❑ ❑ Other Violations <br /> 33. Name of Authorized Representative(print or type) <br /> Signature of Authorized Representative Date <br /> Signature of Reviewing Official Date <br /> Distribution_Original-Field Office,Green- Headquarters, Blue-State's Copy,Yellow- Inspector's Copy, Pink- File Copy IE- 163(1183) <br />