U.S. Department of Labor Legal Identity Report Mine Safety and Health Administration 

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. 

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. 

Form Approved: OMB Number 1219-0042: Approval Expires 12/31/2023

5 C.F.R. 1320.21-Public reporting burden for this collection of information is estimated 

to average 30 minutes per written 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, Office of Standards, Regulations and Variances, 201 12th Street 

South, Suite 401, Arlington, Virginia 22202-5452. Persons are not required to respond 

to this collection of information unless it displays a currently valid OMB Control Number. 

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 

1. Federal Mine Identification Number: 

2. Mine Name: 

3. Directions to this mine: 

4. Mine location address: 

5. Official Business Name of Operator: 

6. Principal Office Address for this Operator: 

7. Telephone number for this mine: 

8. Commodity: 

Update Notice Effective Date: - -

Mine Information 

-

Street Address 

City State Zip Code 

- County 

Street Address 

City State Zip Code 

- Area Code 

Type of Product. 

Telephone Number 

-

Extension 

(In the Event of an Emergency) 

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 Zip Code 

- Foreign Country Foreign Zip Code 

P. O. Box Address 

City Zip Code 

- Area Code Telephone Number Extension E-mail Address 

-

Ownership Information 

12. This Official Business is a: Sole Proprietorship Partnership Corporation Other 

13. Type of Organization: Joint Venture, County Government, Limited Liability Company, etc. If Business is listed as Other, what is the type of 

Organization? 

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. 

State 

State 
15. The lndividual(s) or Organization(s) with ownership interest in this Business or Corporate Officers/Directors are: 

Last Name First Name M l 

a. 

Title 

Organization/Company Name 

Street or P.O . Box Address 

C ity Sta te Zip Code 

I [IJ I I I I - I I I 

Foreign Country Foreign Zip Code 

Last Name First Nam e M l 

b. 

Title 

Organ ization/Com pany Name 

Street or P.O . Box Address 

Check box below 

if a separate sheet 

is attached for 

additional space. 

C ity State Zip Code 

I [I] I I I I I - I I I Foreign Country Foreign Zip Code 

I I 16. If Business is listed as Other, what are the names of Principal Organization Officials or Members? 

Last Name First Name M l 

a . 

T itle 

Street or P.O. Box Address 

City State Zip Code 

I [I] I I I I - I I I Fo reign Country Foreign Zip Code 

Last Na m e First Nam e Ml 

b. 

Title 

Street or P.O . Box Address Check box below 

if a separate sheet 

is attached for 

C additional space. ity S tate Zip Code 

I [TI I I I I I - I I I Foreign Country Foreign Zip Code 

I I 17. If Business is a Corporation, please answer the following : 

a . State of Incorporation: L_J_J b. Is this Corporation a subsidiary? Yes LJ No LJ c. If yes, what is the name and address of your Parent Corporation? 

Name 

Street or P.O . Box Address 

City State Zip Code 

I o::::J I I I I - I I I Foreign Country Foreign Zip Code 

d. Employe r Identification Number for this Business (EIN): I I I - I I I I I I I I 

Privacy Act Notic e. 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 u~ 

to require regulated entities and persons who are doing business with a Federal agency to furnish a TIN. 

Signature and Title of Official Completing Form Date Form Co mpleted 

MSHA Form 2000-7, 

U.S. GPO: 2000-509-451 

A1 (Revised, Previous Editions are Obsolete) Copy 1 - MSHA Wilkes-Barre Assessment Center