Form FS-6 Small Operator Assistance Application

UNITED STATES DEPARTMENT OF THE INTERIOR
OFFICE OF SURFACE MINING RECLAMATION AND ENFORCEMENT

SMALL OPERATOR ASSISTANCE APPLICATION
OMB NO. 1029-0061
EXPIRES: 8/31/2012

Date of Application: __________________

1.

A. BACKGROUND

Permit Applicant's:
_____________________________________________________
FIRST NAME
M.I.
LAST NAME

(____)_______________________
AREA CODE

PHONE NUMBER

______________________________________________________________________________________
COMPANY NAME

______________________________________________________________________________________
UTHORIZED COMPANY OFFICIAL AND TITLE

___________________________________

__________________

______________

CITY

STATE

ZIP

______________________________________________________________________________________
AUTHORIZED COMPANY OFFICIAL AND TITLE

2.

Operator's name and address, if different than applicant:
_________________________________________________________________

3.

Applicant is an individual
corporation

4.

.

(or) a partnership
(or) a
Date of Information: __________________

Has applicant ever been denied Small Operator Assistance? Yes ___ No ___
If yes, attach a full explanation of the circumstances and reasons for denial.

____________________________________________________________________________
PAPERWORK REDUCTION STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C. 35) 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 in order to determine applicant's qualification under the Small Operator Assistance Program. The
obligation to respond is required to obtain a benefit. Proprietary information will be held confidential.
Public reporting burden for this form is estimated to average 18 hours per response 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,
Room 202 SIB, 1951 Constitution Ave, NW, Washington, D.C. 20240.

5.

Has applicant ever had a Small Operator Assistance Project with Either OSM or a State
Regulatory Authority. Yes
No
. If yes, complete below:
PROJECT NAME

CONTRACTOR

OSM OR STATE

DATE SOAP
REPORT RECEIVED

B. PERMIT INFORMATION FOR PROPOSED ASSISTANCE SITE
1.

Is site currently permitted? Yes ___ No ___

2.

If permitted, give: Permit Number _________________ Issue date ___________

3.

What are the anticipated starting and termination dates of the mining operation?
From ______________ To _____________

4.

Name and location of proposed permit site:
a.
b.
c.
d.
e.

5.

NAME:

___________________________________________
COUNTY: _________________________________________
LATITUDE: ________________________________________
LONGITUDE: _______________________________________
NAME OF NEAREST STREAM: ___________________________

Method of Mining (check appropriate box):
AREA STRIPPING
DEEP MINE
CONTOUR STRIPPING

( )
( )
( )

MOUNTAINTOP REMOVAL
AUGER OPERATION
OTHER

( )
( )
( )

If other describe: ___________________________________________
6.

Number of acres in permit area (nearest tenth): ____________________

7.

(a)

(b)

PROBABLE DEPTH OF COAL RESOURCE:
AVERAGE DEPTH TO COAL __________ FEET
MAXIMUM DEPTH TO COAL __________ FEET
PROBABLE THICKNESS OF COAL RESOURCES:

__________FEET __________ INCHES
(c)

Are there multiple seams? Yes ___ No ___
If yes, attach depth and thickness information for each additional seam.

(d)

Estimate of reserves in the permit area and method of calculation.

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8.

State the projected production for each year of the permit area for which assistance is
being sought.
SOAP Site
YEAR (1)

___________________________________________
___________________________________________
YEAR (3) ___________________________________________
YEAR (4) ___________________________________________
YEAR (5) ___________________________________________
YEAR (2)

C. MAPS
Provide U.S. Geological Survey topographical map of 1:24,000 scale or larger, or a topographic
map of equivalent detail which clearly shows:
(a)

The boundaries of the proposed permit area and the natural drainage above and
below the affected area.

(b)

Property boundaries and the name of record for property owners within the
permit area and on adjacent lands.

(c)

The location of existing structures and developed water sources within the permit
area and on adjacent lands.

(d)

The location of existing and proposed test borings or core sampling.

(e)

The location and extent of known workings of any underground mines within the
permit area and adjacent area.

D. DOCUMENTATION
Provide copies of documents which show that:
1.
2.

The applicant has a legal right to enter and mine coal within the permit area; and
A legal right-of-entry has been obtained for the Office of Surface Mining Reclamation
and Enforcement and laboratory personnel to inspect the lands to be mined and
adjacent lands which may be affected to collect environmental data, or to install
monitoring equipment.

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E. ATTRIBUTED PRODUCTION
(during past 12 months)
1.

2.

3.

(a)

Are other mines owned or operated by the applicant? Yes ___ No ___

(b)

Does the applicant control any other mine ("control" means, but is not limited to,
direction of the management)? Yes ___ No ___

(c)

Does the applicant own more than Ten percent (10%) interest in any other coal
mining operation? Yes ___ No ___

(d)

Does any person or corporation own more than a ten percent (10%) interest in
the applicant, or directly or indirectly control the applicant by reason of stock
ownership, direction of the management, or in any other manner whatsoever?
Yes ___ No ___

(e)

Does the applicant have any direct or indirect business relationship between or
among his/her family members and relatives owning coal-producing operations?
Yes ___ No ___

If any of the above five questions (1.(a), (b), (c), (d), or (e)) are answered "Yes", provide
the information listed below for each coal mining operation operated during the past
twelve (12) months. If questions "(c)", "(d)" or "(e)" was answered "Yes", the total and
pro rata share of coal production must be furnished. List each mining operation
separately and attach extra sheets as needed.
(a)

NAME OF COMPANY

(b)

MINE LOCATION

(c)

SURFACE MINE OR UNDERGROUND MINE PERMIT NO.

(d)

MESA

(e)

STATE COAL SEVERANCE TAX VENDOR NO.

(f)

TONS OF COAL PRODUCED

________________________________________________

(County) ______________________ STATE _______________
________________________

(MSHA) I.D. NO FOR THE MINE SITE ________________________________
________________________________

(attach legible copy of coal severance tax return for
each month during most recent 12 months) __________. Pro rata share ______

State the total projected production for each year of the proposed permit for which
assistance is being sought.
Other Operation(s)
YEAR (1)
YEAR (2)
YEAR (3)
YEAR (4)
YEAR (5)

__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

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F. UNDERTAKING OF APPLICANT
The undersigned, as a duly authorized representative of the applicant, hereby agrees that the
applicant intends to apply for a permit pursuant to the regulations and shall, if the applicant
receives small operator assistance:
1.

Fully cooperate with all laboratories, their employees and agents that will produce the
determination and statement:

2.

When requested, submit coal production information for the area affected by this
application and for any other mining operation in which the applicant has an interest or
an operation which has an interest in the applicant; said information is to be furnished
with thirty (30) days of the end of twelve (12) months following issuance of the permit for
which assistance is provided; and,

3.

Notify the Office of Surface Mining Reclamation and Enforcement in writing with 10 days
of any change (a) in ownership or mining plans that may affect assistance eligibility or
permit eligibility pursuant to the information in this application, or (b) that may require a
change in the scope of work being performed by the contractor.

4.

Refund, within 30 days to the Office of Surface Mining Reclamation and Enforcement,
the full amount for small operator assistance paid pursuant to this application (with
computed interest penalty) in accordance with 795.12(a), upon presentation of
appropriate receipts, of any of the following conditions occur:
(a)

Information submitted as required by paragraph (2) above or from the abandoned
mine lands fee compliance system shows actual and attributed coal production to
be in excess of 300,000 tons during the 12-month period following issuance of
the permit for which assistance is provided;

(b)

Knowingly submits false information;

(c)

Fails to submit a permit application within one (1) year from the date of receipt of
the approved laboratory report;

(d)

Fails to commence mining after obtaining a permit;

(e)

Sells, transfers or assigns the permit to another person or company and the
transferee's total actual and attributed production exceeds the 300,000 ton
annual production limit during the 12-month period following permit issuance. In
this case, the applicant and its successor shall be jointly and severally obligated
for reimbursement.

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5.

The operator, represented by the authorized company official (signature below), agrees
to assume responsibility for the care, maintenance and eventual disposal of any groundwater observation wells drilled on their behalf. Upon completion of the Small Operator
Assistant Program study, the use of and responsibility for these wells shall transfer to the
operator. Furthermore, it shall be the responsibility of the operator to meet all
appropriate State and Federal regulations regarding the continued use and/or eventual
abandonment of these wells.

G. AFFIDAVIT
I, _______________________________, as the applicant, or as a duly authorized
representative, being first duly sworn, state that to the best of my knowledge, all information
furnished in this application is true and complete.

by _____________________________________
signature

________________________________________
Title

State of ______________________________________
County of _____________________________________

Subscribed and sworn before me this _________day of ______________________, 20_____.

My commission expires __________________________

______________________________________________
(Notary Public)

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