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r~+v A <br />• • III IIIIIIIIIIIIIIII <br />Pep• 1 al t PaaN <br /> ~/ <br />United States Department of the InteriofU <br />f~F For Office Use Only <br />Office of Surface Mini/11q. (2' <br />Mine Site Evaluation Inspectige~~ q ~ ~ <br />~ ~ <br />~ ,~ ,~ ,~ <br /> <br /> ~BrG"'~j~~ Y Y M M Bstch Repaf <br /> g~ <br /> O,y <br />`Ce n <br />ap D)lon <br />70. n Y ni I <br />2. Name of Permlttee 9. MSHA Number <br />f k <br />t <br /> <br /> 3. Street Addreee 77. State Permit Number <br /> <br /> 4. City 5. State 72. Name of Mlns <br /> <br /> <br />6. Zlp Cotle 7. Area Code 8. Telephone Number 13. County Cotle /4. State Coda 15. Strela 16. State Arae Olllce <br /> <br />17. OSM Field 18. OSM Area 19. OSM 20. Type of Inspectlon 21. Joint Inspectlon 22. Inspector's ID <br />Office No. Olflce No. Sample No. <br />m ~ ~ (Code) Yes No <br />~ ~ <br />~ No. <br /> ' <br />23. Status 24. Type of Activity (check applicable boxes). <br />A m Type of Permlt A ~ Sleep Slope <br />E Anthracite <br />B ~ ~ Mine Status (Code) B ~ Mountain Top Removal F ~ Federal Lands <br />C ~ Type of Facility (COtle) <br />C ~ Prime Farmlands <br />G ~ Intlian Lantls <br />D ~ Number of Permltirrd Acres <br />D ~ Alluvial Valley Floors <br />H ~ Other <br />E (:~ i~ • ;' Number of Dlaturbed Acres <br />25. Performance Stantlerds (Codes) <br />Insuuctbnc Indicate compliance code. For any standard marked 2 or 3 provltle narrallve to support this determination. <br />Standards Thel Llmlt the Elfacte to the Permlt Area Stentlartls That Assure Reclamation Ouallty antl Timeliness <br />A ~ Distance Prohibitions M /~ Topsoil Hantlling <br />B ~ Mlnlnp Wlihln Permlt Boundaries N ~ Backlllllnp antl Gradlnq <br />C ~ Slpns antl Merkere O /^ Following Reclamation Schetlule <br />D /^ Sediment Control Meesurea P ~ Revegatetlon Requlrementa <br />E ~ Dealpn and Certlllcetlon Requirements- O ~ Disposal of Exceae Spoil <br />Sediment Control <br /> <br />F ~ Ef}luant Llmlte <br />R ~ Hantlllnp of Acld or Toxle Materials <br /> S~ Hlghwell Ellminatlon <br />G ~ Sumacs Water Monltorlnp <br /> T ~ Downslope Spoil Dlaposal <br />H ~ Grountl Water Monltorlnp <br />U ~ Post Mlnlnp Land Use <br />I ~ Blaatln9 Procedures <br />V ~ Cessation of Operations: Temporary <br />J ~ HeullAeceaa Road Deelpn and Melntenance <br />W ~ Other <br />K O Refuse Impoundments <br />L ~ Other. Specify <br />DlstrlDutlon: Original -Field Olllca, Green - Heatlquarters, Blue -State's Copy, Yellow -Inspector's Copy, Plnk -File Copy IE - 163 (1/&3) <br />