MSHA 2000-38 Electrical Operated Mining Equipment Field Approval Appl

Electrically Operated Mining Equipment
Field Approval Application (coal operator)

U.S. Department of Labor
Mine Safety and Health Administration

(Complete this form for each electrically operated machine.)

OMB No. 1219-0066, Expires July 31, 2024

Public reporting burden for this form is estimated to average 11 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and submitting the form. This collection of information is mandatory. You are not required to respond to this collection of
information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: 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, VA 22202-5452, Paperwork
Reduction Project (1219-0066). NOTE: Do not send your completed form to this address.

Date of Request

Name and Title of Applicant

Address

Mine in Which Machine will be Used

Mine ID

Type or Model Number

Serial Number

Voltage

Phase

Type of Machine
Hertz

AC or DC

List Components on Machine which are Required to be Permissable (all explosion-proof enclosures, motors, reels, boxes, conduit, etc.)
Component

Manufacturer

Serial or ID Number

MSHA Approval/Certification Number

Do not write in this space – MSHA Use Only
Initial Review of Application

Reset Form

Date of Initial Review of Construction
and Design Requirements

9 Accepted

9 Rejected

9 Section 18.94 Waived

Reasons for Rejection of Application

Signature (authorized electrical representative)
Scheduled Field Inspection

Date

Time

Location

Special Instructions (preparation of machine for field inspection)
Following an initial review by this District Office, your request for a Special Field Approval

of the machine described above has been accepted. Further inspection of the machine will

be required prior to final approval of this application. The inspection will be conducted at

the time and place stated above. Please prepare the machine for inspection and present
this form to the authorized electrical representative at that time.

Result of Field Inspection

Date

Time

Signature (coal mine safety and health district manager)

Location

Reasons for Rejection of Machine
Signature (authorized electrical representative)
Authorization for Issuance of Field Approval for Electrically Operated Mining Machine
To: Approval & Certification Center, RR1, Box 201-b, Triadelphia, WV 26059
I hereby authorize the issuance of a Special Field Approval for the machine described above.
Date

Signature (district manager)

District

Disapproval of Application
For the reasons set forth above, I hereby disapprove your application for Special Field Approval for the machine described above.
Date

Signature (district manager)

MSHA Form 2000-38, (Revised April 2013 - Expiration Date and Burden Statement) (Supercedes MSHA Form 6-1481)

District