U.S. Department of Labor Mine Safety and Health Administration Legal Identity Report 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. Form Approved: OMB Number 1219-0042: Approval Expires -XQH   5 C.F.R. 1320.21-Public reporting burden for this collection of information is estimated to average 30 minutes per writen 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, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. 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. 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 Update Notice - Effective Date: - Mine Information - 1. Federal Mine Identification Number: 2. Mine Name: 3. Directions to this mine: Street Address City 4. Mine location address: State Zip Code County 5. Official Business Name of Operator: Street Address 6. Principal Office Address for this Operator: City State Zip Code Area Code 7. Telephone number for this mine: Telephone Number Extension - (In the Event of an Emergency) Type of Product. 8. Commodity: 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 State Zip Code Foreign Country Foreign Zip Code P. O. Box Address City State Zip Code Area Code Telephone Number Extension E-mail Address Ownership Information 12. This Official Business is a: 13. If Business is listed as Other, what is the type of Organization? Sole Proprietorship Partnership Corporation Other Type of Organization: Joint Venture, County Government, Limited Liability Company, etc. 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. American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com