 |
Arizona Administrative Code (Last Updated: November 17, 2016) |
 |
Title 11. MINES |
|
Chapter 1. STATE MINE INSPECTOR |
|
Article 22. CYANIDE LEACH OPERATIONS |
Appendix A. Cyanide Spill Release Form
All data is extracted from pdf, click here to view the pdf.
-
OFFICE OF STATE MINE INSPECTOR
1700 West Washington, Suite 403
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
___________________________________________________________________________________ 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 #___________________________