Citizen’s Request for an Inspection OMB No. 1029-0118 

Expires 12/31/2023

United States Department of the Interior

Office of Surface Mining Reclamation and Enforcement

Attn: Division Chief 

Division of Regulatory Support

1849 C Street, N.W., MIB 4550

 Washington, D.C. 20240 

Fax: (202) 219-3276

Instructions: All questions marked with a red asterisk (*) are required before submitting this form.

1. Citizen’s Contact Information

a. Name*

b. E-Mail Address

c. Street Address*

d. City* e. State* f. Zip Code*

g. County

h. Telephone*

2. Coal Mine Site Information

a. Coal Mine Operator’s or Company’s Name*

b. Mine site and/or Project Name*

c. State or Tribal lands where the coal mine is located (e.g., Alabama, Navajo Reservation)*

d. Permit Number (if known)

3. Violation Information

a. Nature and extent of the problem (select one)*

Violation of the law, regulations or permit conditions 

Imminent danger to public health or safety 

Significant, imminent environmental harm

Office of Surface Mining Reclamation and Enforcement Rev. October 20
b. Type of problem (select one)*

Polluted water

Sudden loss of water 

Blasting or explosives problems 

Unstable backfills or grading 

Subsidence of land over an underground mine 

Multiple problems

Other type of complaint (Described below)

c. Please describe conditions at the mining site which you believe are in violation of the law. If

additional space is needed, add to email message when prompted.

4. E-Mail Confirmation

Would you like to receive a confirmation e-mail message when your request for an inspection is 

received and read (select one)?*

Yes (Check here if you want an e-mail confirmation when we read your request) 

No, I would like to follow the traditional procedure and receive written confirmation of my request 

in the mail

PAPERWORK REDUCTION STATEMENT

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501) requires us to inform you that: Federal Agencies may not conduct or sponsor, and a 

person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. This information is 

being collected to allow citizens to request an inspection if you believe a violation at a mine site exists. The obligation to respond is required to 

obtain a benefit. Confidentiality is required under 30 CFR 842.12(b) and (e) and 30 CFR 721.13 (a)(2) and (c)(4) to protect the identity of 

people supplying information to OSMRE, if they request it. Your name will remain confidential by OSMRE unless you accompany the 

inspector on an inspection, or unless disclosure is required under the Freedom of Information Act (FOIA) or other Federal law. Any 

information you submit to OSMRE may be subject to disclosure. However, the information will be treated in accordance with the 

requirements of the FOIA (5 U.S.C. 552, as amended) and the Privacy Act of 1974 (5 U.S.C. 552a). Public reporting burden for this collection 

is estimated to average 1 hour, including time for reviewing instructions, gathering and maintaining data, and completing and reviewing the 

form. Direct comments regarding the burden estimate or any other aspect of this form to the Information Collection Clearance Officer, Office of 

Surface Mining Reclamation and Enforcement, 1849 C. Street, NW, MIB 4556, Washington, D.C. 20240. 

Office of Surface Mining Reclamation and Enforcement Rev. October 20