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Page 1 of 2 Pages <br /> United States Department of the Interior For Office Use Only <br /> Office of Surface Mining 1a 1b 1c <br /> Mine Site Evaluation Inspection Report M <br /> L <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 /> -L <br /> U I ID � � I r <br /> 3. Street Address 11. State Permit Number <br /> 4.City 5.State 12 NamP of Mine _ <br /> FtT[T M IM L, I I I L-ILLLULLI <br /> 6.Zip Code 7.Area Code 8 Telephone Number �13. County Code 14�State Cooe 15 Strata I166 State Area Office <br /> n L_L_L LJ—I I� L1-� <br /> 17.OSM Field 18.OSM Area 19 OSM 20.Type of Inspectior 21 Joint Inspection 22 Inspectors ID <br /> Office No. Office No. Sample No. (Code) Yes No No. <br /> F� Fj F-T-71 <br /> 23. Status 24 Type of Activity(ctieck applicable boxes) <br /> A m Type of Permit <br /> A � Steep Slope E � � Anthracite <br /> B Mine Status(Code) <br /> B � Mountain iop Removal F Federal Lands <br /> C m Type of Facility(Code) <br /> C [� Prime Farmlands G C, Indian Lands <br /> D • Number of Permitted Acres <br /> D Alluvial Valley Floors H l] Other <br /> E Number of Disturbed Acres L—' <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 Reclamat;or, Ouality and Timeliness <br /> A Distance Prohibitions M LJ Topsoil Handling <br /> B Mining Within Permit Boundaries N L Backfillinq and Grading <br /> C Signs and Markers O Following Reclamation Schedule <br /> D Sediment Control Measures P Revege!ation 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 � Effluent Limits <br /> S Hlghwall 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 I - 163(1/83) <br />