Form DMM-166 "Contractor Identification Form" - Virginia

What Is Form DMM-166?

This is a legal form that was released by the Virginia Department of Mines, Minerals and Energy - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Virginia Department of Mines, Minerals and Energy;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DMM-166 by clicking the link below or browse more documents and templates provided by the Virginia Department of Mines, Minerals and Energy.

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Download Form DMM-166 "Contractor Identification Form" - Virginia

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DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE. 400
CHARLOTTESVILLE, VIRGINIA 22903
(434) 951-6310
CONTRACTOR IDENTIFICATION FORM
Section 45.1-161.292.32 of the Mineral Mine Safety Laws of Virginia requires that the applicant for a mine
license include information about contractors working at the mine and keep the information current by reporting
any change within 30 days. This sheet may be attached to the License Renewal Application in response to
Question 4.
Licensed Operator Information
COMPANY
PERMIT #
Location at mine where work is to be done
Date contractor began work on the mine
Date contractor information was provided to the Division of Mineral Mining in writing
Person who provided the information
SIGNATURE OF LICENSED MINE OPERATOR
DATE
Contractor Information
Contractor’s Trade Name
Business Address
Business Telephone Number
DMM Contractor #
Contractor’s MSHA Identification #
(Note: Not all contractors are required to have a DMM Contractor ID or MSHA ID number. This information should be
provided if applicable.)
Address of Record for Service of Citations and Other Documents
List services to be provided to the mining company:
Contractor person with responsibility for operating decisions:
Name
Address
Contractor person responsible for health and safety of employees:
Name
Address
DMM-166
Rev 05/16
DIVISION OF MINERAL MINING
900 NATURAL RESOURCES DRIVE, STE. 400
CHARLOTTESVILLE, VIRGINIA 22903
(434) 951-6310
CONTRACTOR IDENTIFICATION FORM
Section 45.1-161.292.32 of the Mineral Mine Safety Laws of Virginia requires that the applicant for a mine
license include information about contractors working at the mine and keep the information current by reporting
any change within 30 days. This sheet may be attached to the License Renewal Application in response to
Question 4.
Licensed Operator Information
COMPANY
PERMIT #
Location at mine where work is to be done
Date contractor began work on the mine
Date contractor information was provided to the Division of Mineral Mining in writing
Person who provided the information
SIGNATURE OF LICENSED MINE OPERATOR
DATE
Contractor Information
Contractor’s Trade Name
Business Address
Business Telephone Number
DMM Contractor #
Contractor’s MSHA Identification #
(Note: Not all contractors are required to have a DMM Contractor ID or MSHA ID number. This information should be
provided if applicable.)
Address of Record for Service of Citations and Other Documents
List services to be provided to the mining company:
Contractor person with responsibility for operating decisions:
Name
Address
Contractor person responsible for health and safety of employees:
Name
Address
DMM-166
Rev 05/16