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V r C <br /> s RECEIVE® <br /> 7-g-3 1 <br /> Page 1 of 2 Pages <br /> United States Department of the Interior MINED UND r Office Use Only <br /> Office of Surface Mining RECLAMATION DIVIS���i ib ,C <br /> Mine Site Evaluation Inspection Report gm r- <br /> W <br /> ] M <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 /> Ll � T— <br /> � �_ I Ll— __J <br /> 3. Street Address 11 State Permit Number <br /> T—Ir- <br /> _L7i , <br /> 4. City 5 State 12 Name of Mine <br /> I <br /> _I I � LJ_ <br /> 6.Zip Code 7 Area Code 8.Telephone Number 13 County Code 14 State Cooe 15 Strata 16 State.Area Office <br /> 1 -1 <br /> 1 "7 1111 n LITRT��� � � LLT <br /> -j <br /> 17. OSM Field 18. OSM Area 19 OSM 20 Type of Inspe�tior 21 Joint Inspection 22 Inspectors ID <br /> Office No. Office No. Sample No (Code)_ Yes No No <br /> i I <br /> P ID I E—,1 117 <br /> 23. Status 24 1ype of Activity(check applicable boxes) <br /> A m Type of Permit <br /> A � Steep Slope E � � Anthracite <br /> B Mine Status(Code) <br /> B �i Mountain Fop Removal F Federal Lands <br /> C m Type of Facility(Code) _ <br /> C [ J Prime Farmlands G C� Indian Lands <br /> D Number of Permitted Acres <br /> D Alluv,al 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 Assu,e Reclamation Odniity and Timeliness <br /> A Distance Prohibitions M Topsoil Handling <br /> B Mining Within Permit Boundaries N C� Backtilling and Grading <br /> C Signs and Markers O L Following Reclamat�or. Schedi:Ie <br /> D Sediment Control Measures P Reveyetation Requirements <br /> E Design and Certification Requirements— O Disposal of Excess Spoil <br /> Sediment Control <br /> R Handling of Acid or Toxic Materials <br /> IF F] Effluent Limits <br /> S Highwall Elimination <br /> G � Surface Water Monitoring <br /> T Downslope Spoil Disposal <br /> �H Ground Water Monitoring <br /> U Post Mining Land Use <br /> 1 Blasting Procedures <br /> V 1:1 Cessation of Operations Temporary <br /> J Haul/Access Road Design and Maintenance <br /> W F—] 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 I - 163(1183) <br />