Annual Report

Name of Person/Firm Engaged in Mining

Location of the Mine(s)

Number of Acres

Number of Audits

Number of Open Pits

Number of Shafts

Number of Slopes

Number of employees

Average Annual Wages Paid

Amount (Tons) of Mineral(s) Produced

Number and Brief Description of Incidents Resulting in Irreversible Injury

Number and Brief Description of any Incidents Resulting in Fatality

Contact Information for person Submitting this Form

Name

Phone

By Division