Arizona Administrative Code › Title 11 - MINES › Chapter 1 - STATE MINE INSPECTOR › Article 22 - CYANIDE LEACH OPERATIONS › Appendix A - Cyanide Spill Release Form

Current through Register Vol. 30, No. 28, July 12, 2024
OFFICE OF STATE MINE INSPECTOR
1700 West Washington, Suite 403
Phoenix, Arizona 85007 (602) 542-5971
CYANIDE SPILL RELEASE FORM
STATE ID# ______________________________ MSHA ID#
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COMPANY
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MAIL ADDR.
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CITY ___________________________________ STATE
				  ______________________________ ZIP __________________
MINE/PLANT NAME
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LOCATION - RANGE _______________________ TOWNSHIP
				  _______________________ SECTION _____________
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DATE SPILL OCCURRED TIME SPILL OCCURRED
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TIME STATE MINE INSPECTOR'S LOCATION OF SPILL
OFFICE NOTIFIED OF SPILL
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TYPE OF MINING OPERATION TYPE & BRAND OF CYANIDE
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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?
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PERSON SUBMITTING REPORT
				  _____________________________________________ DATE ___________________
TITLE
				  _________________________________________________________ PHONE #
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