Fillable Office of Surface Mining Reclamation and Enforcement OMB (Office of Surface Mining)

Fill Online, Printable, Fillable, Blank Office of Surface Mining Reclamation and Enforcement OMB (Office of Surface Mining) Form

Use Fill to complete blank online OFFICE OF SURFACE MINING (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Office of Surface Mining Reclamation and Enforcement OMB (Office of Surface Mining)

On average this form takes 6 minutes to complete

The Office of Surface Mining Reclamation and Enforcement OMB (Office of Surface Mining) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of Surface Mining

BROWSE OFFICE OF SURFACE MINING (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Citizen’s Request for an Inspection
OMB No. 1029-0118
Expires 12/31/2020
United States Department of the Interior
Office of Surface Mining Reclamation and Enforcement
Attn: Division Chief
Division of Regulatory Support
1849 C Street, N.W., MIB 4550
Washington, D.C. 20240
Fax: (202) 219-3276
Instructions: All questions marked with a red asterisk (*) are required before submitting this form.
1. Citizen’s Contact Information
a. Name*
b. E-Mail Address
c. Street Address*
d. City*
e. State*
f. Zip Code*
g. County
h. Telephone*
2. Coal Mine Site Information
a. Coal Mine Operator’s or Company’s Name*
b. Mine site and/or Project Name*
c. State or Tribal lands where the coal mine is located (e.g., Alabama, Navajo Reservation)*
d. Permit Number (if known)
3. Violation Information
a. Nature and extent of the problem (select one)*
Violation of the law, regulations or permit conditions
Imminent danger to public health or safety
Significant, imminent environmental harm
Office of Surface Mining Reclamation and Enforcement
Rev. October 20
12345
(999) 999-9999
(STATE/Tribal Land)
b. Type of problem (select one)*
Polluted water
Sudden loss of water
Blasting or explosives problems
Unstable backfills or grading
Subsidence of land over an underground mine
Multiple problems
Other type of complaint (Described below)
c. Please describe conditions at the mining site which you believe are in violation of the law. If
additional space is needed, add to email message when prompted.
4. E-Mail Confirmation
Would you like to receive a confirmation e-mail message when your request for an inspection is
received and read (select one)?*
Yes (Check here if you want an e-mail confirmation when we read your request)
No, I would like to follow the traditional procedure and receive written confirmation of my request
in the mail
PAPERWORK REDUCTION STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. This information is
being collected to allow citizens to request an inspection if you believe a violation at a mine site exists. The obligation to respond is required to
obtain a benefit. Confidentiality is required under 30 CFR 842.12(b) and (e) and 30 CFR 721.13 (a)(2) and (c)(4) to protect the identity of
people supplying information to OSMRE, if they request it. Your name will remain confidential by OSMRE unless you accompany the
inspector on an inspection, or unless disclosure is required under the Freedom of Information Act (FOIA) or other Federal law. Any
information you submit to OSMRE may be subject to disclosure. However, the information will be treated in accordance with the
requirements of the FOIA (5 U.S.C. 552, as amended) and the Privacy Act of 1974 (5 U.S.C. 552a). Public reporting burden for this collection
is estimated to average 1 hour, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the
form. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of
Surface Mining Reclamation and Enforcement, 1849 C. Street, NW, MIB 4559, Washington, D.C. 20240.
Office of Surface Mining Reclamation and Enforcement
Rev. October 20
Print
Reset
Submit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Office of Surface Mining Reclamation and Enforcement OMB (Office of Surface Mining)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document