U.S. Department of Labor
Legal Identity Report
Mine Safety and Health Administration
This report is required by law (30 C.F.R. 41). Failure to report can result in assessment of a civil penalty.
Knowingly making a false statement can result in criminal prosecution under Section 110 of the Federal Mine
Safety and Health Act of 1977. This report should be prepared only by an official with full knowledge of
ownership information. This report must be signed by the Official completing the form to be valid. Type or
print in ink only. If more space is required in any section below, use a separate sheet. Instructions are on the
reverse side of the last page.
NOTE: You must mail copies 1 and 2 of this completed form to your local MSHA office. Questions
about filing this form should be directed to the Wilkes-Barre Assessment Center, 570-826-6431.
Form Approved: OMB Number 1219-0042: Approval Expires 12/31/2023
5 C.F.R. 1320.21-Public reporting burden for this collection of information is estimated
to average 30 minutes per written response and 20 minutes per electronic response,
including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data need, and completing and reviewing the collection of
information. Send comments regarding the collection of information, including
suggestions for reducing this burden, 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, Virginia 22202-
5452. Persons are not required to respond
to this collection of information unless it displays a currently valid OMB Control Number.
ALL INFORMATION PREVIOUSLY SUBMITTED REMAINS IN EFFECT EXCEPT WHERE CHANGES HAVE BEEN SUBMITTED. IF THE CHANGES PROVIDED ON THIS
FORM AFFECT OTHER MINES, A SEPARATE FORM MUST BE FILED FOR EACH MINE IDENTIFICATION NUMBER.
Initial Notice
1. Federal Mine Identification Number:
2. Mine Name:
3. Directions to this mine:
4. Mine location address:
5. Official Business Name of Operator:
6. Principal Office Address for this Operator:
7. Telephone number for this mine:
8. Commodity:
Update Notice Effective Date:
- -
Mine Information
-
Street Address
City
State Zip Code
-
County
Street Address
City State Zip Code
-
Area Code
Type of Product.
Telephone Number
-
Extension
(In the Event of an Emergency)
Type of Operation.
9. Person at Mine in Charge of Health and Safety: (Superintendent or Principal Officer)
Last Name First Name MI
Title
Street or P.O. Box Address
City
State Zip Code
-
E-mail Address
10. Person with Overall Responsibility for a Health and Safety Program at ALL of the Operator's Mines, if the Operator is Not Directly Involved in the Daily Operation
of the Mine: (Safety Director)
Last Name First Name MI
Title
Street or P.O. Box Address
City
State Zip Code
-
E-mail Address
11. Address of Record and Telephone Number: [Address and Person designated to receive Official Mail - Service of documents upon the operator will be completed by mailing
or personal service of the documents to this address. If P.O. Box or General Delivery is used for mailing address, a separate street address for personal service must be
provided. ]
Last Name First Name MI
Title
Street Address
City Zip Code
-
Foreign Country Foreign Zip Code
P. O. Box Address
City Zip Code
-
Area Code Telephone Number Extension E-mail Address
-
Ownership Information
12. This Official Business is a: Sole Proprietorship Partnership Corporation Other
Type of Organization: Joint Venture, County Government, Limited Liability Company, etc.
13. If Business is listed as Other, what is the type of
Organization?
14. Tax Identification Number (TIN) for this Business: For individuals, this is your social security number (SSN). For other entities, this is your employer identification number
(EIN).
SSN for Individuals: EIN for Entities
- - -
Privacy Act Notice. We are authorized to request this information under the Debt Collection Improvement Act of 1996, Title 31 U.S.C. amended section 7701, new subsection (c)(1), which mandates us
to require regulated entities and persons who are doing business with a Federal agency to furnish a TIN.
State
State
