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□ □ □ Modesto Fire Department FIRE PREVENTION DIVISION 409 12th Street, Modesto, California 95354 Tel: (209) 571-5553 Fax: (209) 544-1652 EXPLOSIVES APPLICATION AND PERMIT Application Date: Permit Issued Date: 1. Permittee. Blaster’s License Number: Expires: DOB: Name: Address: Phone: Age: Hgt: Wgt: Color Eyes: Color Hair: Sex: Drivers Lic. No: (Min. 21) Representing: 2. Vehicle for Transp. Make: Model: Yr: Plate No: State: Travel Route in Modesto & Safe Stopping Places: 3. Activities (mark all that apply). Manufacture Store Receive and/or transport Use Sell or otherwise dispose Oper. Terminal Park vehicle 4. Material. Type and quantity of explosive: How and where stored: How and where used: Printed Name of Permittee Signature of Permittee This permit is granted on to perform those activities noted herein. Permit expires (date) (max 1 year from date granted) This permittee is limited to performing these activities: Printed Name of Issuing Authority Signature of Issuing Authority _ Returned to the source Totallydestroyed Turned over to the authority issuing the permit or reapply for a new permit will be disposed of in the following manner on or before the expiration date: orders to perform those activities noted herein. I also understand that all unused inventory covered by this permit I, the undersigned, certify that I understand and will abide by all Federal, State and Local laws, ordinances, rules or This permit is not transferable. 5. Restrictions: Permittee shall notify the Fire Prevention Division on a weekday 24 hours prior to blasting:[PHONE REDACTED] Fee: $492.00 (Includes one Inspection) Application & Permit Number: revised 7/21/20 programs, or activities. For more information, please visit the City of Modesto website at codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Copy of receipt purchase shall be returned to this office. Terminal approvals shall be forwarded to: California Highway Patrol –Motor Carrier Safety Selection, 2611 – 26th Street, Sacramento, CA 95814 Law Enforcement (Sheriff’s Office/Police) Chief fire authority where explosives to be stored or used. State Bureau of CII, Sacramento Issuing Authority Permittee Distribution: SIGN