Ariz. Admin. Code § tit. 11, ch. 1, art. 22, app A

Download

PDF

Current through Register Vol. 30, No. 24, June 14, 2024

Appendix A - Cyanide Spill Release Form

OFFICE OF STATE MINE INSPECTOR

1700 West Washington, Suite 403

Phoenix, Arizona 85007 (602) 542-5971

CYANIDE SPILL RELEASE FORM

STATE ID# ______________________________ MSHA ID# ________________________________________________

COMPANY

__________________________________________________________________________________________________

MAIL ADDR. __________________________________________________________________________________________________

CITY ___________________________________ STATE ______________________________ ZIP __________________

MINE/PLANT NAME __________________________________________________________________________________________________

LOCATION - RANGE _______________________ TOWNSHIP _______________________ SECTION _____________

________________________________________ ___________________________________________

DATE SPILL OCCURRED TIME SPILL OCCURRED

________________________________________ ___________________________________________

TIME STATE MINE INSPECTOR'S LOCATION OF SPILL

OFFICE NOTIFIED OF SPILL

________________________________________ ___________________________________________

TYPE OF MINING OPERATION TYPE & BRAND OF CYANIDE

________________________________________ ___________________________________________

WHERE OBTAINED AMOUNT SPILLED

HOW DID SPILL OCCUR? HOW MANY PEOPLE WERE PRESENT AT TIME OF SPILL AND WAS ANYONE INJURED? IF SO, HOW WERE THEY TREATED AND HOW WAS AREA MADE STABLE? ____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

PERSON SUBMITTING REPORT _____________________________________________ DATE ___________________

TITLE _________________________________________________________ PHONE # ___________________________

Ariz. Admin. Code tit. 11, ch. 1, art. 22, app A

Adopted effective July 6, 1993 (Supp. 93-3).