Electrically Operated Mining Equipment Field Approval Application (coal operator) U.S. Department of Labor Mine Safety and Health Administration (Complete this form for each electrically operated machine.) OMB No. 1219-0066, Expires August 31, 2008. Public reporting burden for this collection of information is estimated to average 11 minutes per 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, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209. Date of Request Name and Title of Applicant Address Mine in Which Machine will be Used Mine ID Type or Model Number Serial Number Voltage Phase Type of Machine 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 this form to the authorized electrical representative at that time. Result of Field Inspection Date Time Signature (coal mine safety and health district manager) Location Reasons for Rejection of Machine Signature (authorized electrical representative) 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 Disapproval of Application For the reasons set forth above, I hereby disapprove your application for Special Field Approval for the machine described above. Date Signature (district manager) MSHA Form 2000-38, June 84 (Revised) (Supercedes MSHA Form 6-1481) District American LegalNet, Inc. www.USCourtForms.com