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
(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
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