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Date t o /M / 2- <br />Mine Name/Permit Number C v (0 0-1 o C e11J 1/4 /a-e" / C ' / 61 -0/q <br />Inspector Signature <br />Based on your ON -SITE Observation, please answer the following: <br />1) Mine ID sign ,� <br />a) Permittee C f 0 `" • j 0 cod Cm i" (�C t , �� - <br />1` r 1 J <br />b) Operator <br />c) MSHA I/ 5 0 2- � ' 2 (not required to be on sign) <br />2) Direct inquiry (of persons on the site) it <br />C & IV w/o c y r � Cdnip. t / i . P <br />() 1 tl <br />a) Permittee <br />b) Operator <br />c) MSHA Ili <br />If No, what is in conflict? <br />AVS Annual Review <br />Inspection Worksheet <br />3) Is ownership /control information for permittee and operator noted in field consistent with <br />what is listed in the permit application? Yes v'" No <br />DRMS is required to verify this information as specified in the AVS MOU if the permitting action was <br />approved subsequently to the MOU (renewal, transfers and revisions). Annually as long as coal <br />extraction from the site has not been completed, DRMS must determine whether officer /controller <br />information is complete and accurate in AVS. In making the determination of complete and accurate <br />information, on -site observations and direct inquiry of persons on the site is necessary. The information <br />on this form will be verified with AML, MSHA, and EIA information in AVS. Please return the form to <br />Mary Rodriguez to be verified in the AVS. <br />