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All <br /> � R <br /> Page 1 of 2 Pages <br /> United States Department of the Interior SEP 1984 For Office Use Only <br /> Office of Surface Mining is lb is <br /> Mine Site Evaluation Inspection RepoMINED LAND RECLAI IATIO IVI I N I[] IDColo. Dept of Nat ral R <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 /> � � I I � I � I I � F7 El I I I I I I � I I I I I <br /> 6.Zip Code 7.Area Code 8.Telephone Number 13 County Code 14. State Code 15.Strata 16.State Area Office <br /> 11FM [11 IE ID <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 /> [I] E 11111 � � I � E E FEE <br /> 23.Status 24.Type of Activity(check applicable boxes). <br /> A m Type of Permit <br /> A � Steep Slope E � Anthracite <br /> B m 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 El 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 ❑ Mining Within Permit Boundaries N Backfilling and Grading <br /> C F-1 Signs and Markers O El Following Reclamation Schedule <br /> D F-1 Sediment Control Measures P Revegetation Requirements <br /> E Design and Certification Requirements— Q 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 /> G Surface Water Monitoring <br /> T � Downslope Spoil Disposal <br /> H ❑ Ground Water Monitoring <br /> U � Post Mining Land Use <br /> I 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(1183) <br />