U.S. Department of Labor
Mine Safety and Health Administration
Mine Operator Identification Request
Approved OMB No.: 1219-0042 / Expires: Sept. 30, 2020
Mine Identification Number
Check Appropriate Box
Metal/Nonmetal Coal
Date
Operating Company Name
Mine/Plant Name
Mailing Address For Document Delivery (Same as on Legal Identity Form)
City State Zip Code
Contact Official Title Phone
Nearest Town to Mine State County
Status Date
Office Code County Code (FIPS)
Public reporting burden for this form is estimated to average 20 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: Mine Safety & Health Administration, U.S. Department of Labor,
Office of Standards, Regulations and Variances, 201 12th Street South, Suite 4E401., Arlington, VA 22202-5452, Paperwork Reduction Project
(1219-0042). NOTE: Do not send your completed form to this address.
This form is affected by the Privacy Act of 1974
Mine Type (Subunit)
(01) Underground
(03) Strip, Quarry, Pit, Dragline
(04) Auger
(05) Culm Bank, Refuse Pile
(06) Dredge
(12) Other Mining
(17) Independent Shops & Yards
(30) Prep Plant, Mill, Tipple
Metal/Nonmetal Mine Data
Status of Operation SIC Code Travel Area
Coal Mine Data
ADIB Use
Status of Operation
SIC Code Work Group
District/Field Office
Name of MSHA Employee Requesting Number
Office Telephone FAX Number
FAX Verification
Coder Number:
FAX Number: (303) 231-5515
Attn:
ADIB
FAX Number:
Attn:
Date
Date
Time:
Time:
Sender
Sender
ADAA CF CG BA
BDAC
BC
BB
BE
AB
CH
CB
MSHA 7000-51
Aug. 2015
