Applications for waivers of the requirements of §§ 75.1712-1 through 75.1712-3 shall be filed with the Coal Mine Safety District Manager and shall contain the following information:

(a) The name and address of the mine operator;

(b) The name and location of the mine;

(c) A statement explaining why, in the opinion of the operator, the installation or maintenance of the facilities is impractical or unnecessary.