Form 2000-38 Electrically Operated Mining Equipment Field Approval Ap

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 XXXX XX, XXXX

When an operator decides to make field modifications to approved (permissible) equipment, he shall apply in writing to make such modifications in accordance with 30 CFR 18.81. The proposed modifications shall conform with the applicable requirements and shall not substantially
alter the basic functional design of the originally approved equipment. The application along with the plans for the modification shall be filed
with the MSHA Approval and Certification Center, which may examine, investigate and approve the changes.
Public reporting burden for this collection of information is estimated to average 11 minutes per 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, Records Management Branch, 1100 Wilson Boulevard, Arlington, Virginia 22209-3939. Persons are
not required to respond to this collection of information unless it displays a currently valid Control number.
Date of request

Name and title of applicant

Address

Mine in which machine will be used

Mine ID

Type or model number

Serial number

Type of machine

Voltage

Phase

Hertz

AC or DC

List components on machine which are required to be permissible (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

Date of initial review of construction
and design requirements

Accepted

Rejected

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

Signature (coal mine safety and health district manager)

Time

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
MSHA Form 2000-38, March 03 (revised)

Signature (District Manager)

District