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40 IX'W vtrr <br /> oefPage 1 of 2 Pages <br /> C 4 <br /> United States Department of the Interior'DE •����or Office Use Only <br /> Office of Surface Mining + °� , ' <br /> Mine Site Evaluation Inspection R"A 3 � � %Xt M11 <br /> ,b ,� <br /> �,�1ft. �� ItM 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 /> t LLL—t I I I—11 �1 M <br /> 3. Street Address 11 State Permit Number <br /> _]� <br /> T�TTM Ll i H <br /> 4.City 5 State r12 Name of Mine <br /> ITI <br /> M Tqn,I � � � � � <br /> I LL <br /> L 1 1 ! <br /> 6 Zip Code 7. Area Code 8 Telephone Number 13 County Code 14 State Code 15 Strata 166 State.Area Office <br /> I M, <br /> [ M-H -111D M T LL L <br /> 17.OSM Field 18 OSM Area 19. OSM 20 Type of InspecUer 21 Joint Inspection 22 Inspector's ID <br /> Office No Office No. Sample No (Code) Yes No No <br /> LI <br /> 23.Status 24 type of Activity(check applicable boxes) <br /> A m Type of Permit r_ _ <br /> A Steep Slope E Anthracite <br /> B W Mine Status(Code) LJ <br /> B Mountain rop Remo,al F �� Federal Lands <br /> C m Type of Facility(Code) <br /> Prime Farmlands G Indian Lands <br /> D • ] Number of Permitted Acres _ <br /> D L Alluvial Valley Floors H l� 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 Reclamahor Duality and Timeliness <br /> A Distance Prohibitions M J Topsoil Handling <br /> B ❑ Mining Within Permit Boundaries N Backtilhnq and Grading <br /> C Signs and Markers O L J Following Reclamation Schedule <br /> D Sediment Control Measures P Revegetation Requirements <br /> E Design and Certification Requirements— 0 Disposal of Excess Spoil <br /> Sediment Control <br /> R Handling of Acid or Toxic Materials <br /> F F] Effluent Limits <br /> S Highwall Elimination <br /> G1-1 Surface Water Monitoring <br /> T L J Downslope Spoil Disposal <br /> H � Ground Water Monitoring <br /> U Post Mining Land Use <br /> I � Blasting Procedures <br /> V C] 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 - Headquart , Blue-State's Copy, ellow - Inspector's Copy Pink.- File Copy I - 163(1/83) <br />