2. Application Date:*
   Application Date:
4. Applicant Name:*
5. Business Name:*
7. Address:*
9. City*
10. State*
11. Zip*
13. F.I.N. :*
14. Email Address:
16. Daytime Telephone:*
17. After Hours Telephone:*
19. Mobile/Emergency Telephone:*
21. Certificate of Insurance:*
22. Date of Expiration:*
    Date of Expiration:
24. List all certified blasters operating at this site:
26. NAME:*
27. CERTIFICATION NUMBER:*
28. EXPIRATION DATE:*
30. NAME:*
31. CERTIFICATION NUMBER:*
32. EXPIRATION DATE:*
34. NAME:*
35. CERTIFICATION NUMBER:*
36. EXPIRATION DATE:*
38. Type of operation applying for:*
    -- Select One --Use of explosivesStorage of explosives
39. *Code requires that caps/detonators be stored in separate magazines. A separate permit is required for the storage of caps/detonators.
41. Physical Address of Jobsite:*
42. Tax Number:*
44. Property Owner Name:*
46. Address (if different):
47. Telephone Number:
51. CAPS/DETONATORS
53. Type of caps/detonators:*

    1. Electrically operated
    2. Other (explain)
54. Other Explain:
56. If using caps other than electric, indicate milli-second delays:
58. Total Amount on Hand:*
59. Type on Hand:*
    -- Select One --CapsCases
63. EXPLOSIVES
65. Type of Explosive:*
67. Total Amount on Hand:*
68. Quantity*
    -- Select One --PoundsCases
70. Type of Blasting Operation:*

    1. Construction
    2. Excavation
    3. Other (explain)
71. Other Explain:
75. Projected Start Date*
    Projected Start Date
76. Projected End Date:*
    Projected End Date:
78. Distance between blast site and nearest Magazine:
79. Distance between blast site and nearest Structure:
81. Type of structure:
85. Air blast/ground vibration recorded by:*
    -- Select One --Charge weight delay, by distancePeak particle velocity, by distanceParticle velocity, dependant on frequency contentOther, explain
86. Other, explain:
88. Seismograph:

    If using, does it conform to the requirements of the City of Waynesboro entitled instrumentation?

    1. Yes
    2. No
92. MAGAZINES:
94. Number of:
95. Capacity:
96. Serial Number:
98. Barricaded ?
    -- Select One --YesNo
99. Placard System Used:
    -- Select One --DOTNFPA 701Military
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101. 1. Receive an email copy of this form.
102. Email address

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103. Submit

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