Electrically Operated Mining Equipment U.S. Department of Labor
Field Approval Application (coal operator) Mine Safety and Health Administration
(Complete this form for each electrically operated machine.)
Date of Request Name and Title of Applicant Address
Mine in Which Machine will be Used Mine ID
Type or Model Number Serial Number Type of Machine
Voltage Phase Hertz AC or DC
List Components on Machine which are Required to be Permissable (all explosion-proof enclosures, motors, reels, boxes, conduit, etc.)
Component Manufacturer Serial or ID Number MSHA Approval/Certification Number
Do not write in this space – MSHA Use Only
Initial Review of Application Date of Initial Review of Construction
and Design Requirements
9 Accepted 9 Rejected 9 Section 18.94 Waived
Reasons for Rejection of Application
Signature (authorized electrical representative)
Scheduled Field Inspection Date Time Location
Special Instructions (preparation of machine for field inspection)
Following an initial review by this District Office, your request for a Special Field Approval
of the machine described above has been accepted. Further inspection of the machine will
be required prior to final approval of this application. The inspection will
be conducted at
the time and place stated above. Please prepare the machine for inspection and present Signature (coal mine safety and health district manager)
this form to the authorized electrical representative at that time.
Result of Field Inspection Date Location
Reasons for Rejection of Machine
Signature (authorized electrical representative)
Time
Authorization for Issuance of Field Approval for Electrically Operated Mining Machine
To: Approval & Certification Center, RR1, Box 201-b, Triadelphia, WV 26059
I hereby authorize the issuance of a Special Field Approval for the machine described above.
Date Signature (district manager) District
For the reasons set forth above, I hereby disapprove your application for Special Field Approval for the machine described above.
Date Signature (district manager) District
Disapproval of Application
Public reporting burden for this form is estimated to average 11 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and submitting the form. This collection of information is mandatory. You are not required to respond to this collection of
information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: to the Mine
Safety and Health Administration, U.S. Department of Labor, Office of Standards Regulations and Variances, 201 12th Street South, Suite 401, Arlington, VA 22202-5452, Paperwork
Reduction Project (1219-0066). NOTE: Do not send your completed form to this address.
OMB No. 1219-0066, Expires July 31, 2024
MSHA Form 2000-38, (Revised April 2013 - Expiration Date and Burden Statement) (Supercedes MSHA Form 6-1481)
