1. 1. Permittee:

   Name __________ Blasters Permit No. __________

   Address

   Color

   Color

   Drivers

   Age___ (Min. 21) Hgt.___Wgt.___Eyes___Hair___Sex___Lic. # ___

   Representing

2. 2. Vehicle for Trans: Make _____Model_____ Yr. _____ Lic. No. _____

   State Registration__________ Travel Route & Safe Stopping Places __________

3. 3. Activity: Manufacture​ Store​ Receive and/or Transport​ Use​

   Sell or otherwise dispose​ Oper. Terminal* ​ Park Vehicle ​

4. 4. Material: Type of Explosive __________ Quantity__________lbs.

   1. (1) Returned to source
   2. (2) Totally destroyed

   3. (3) Turned over to the authority issuing the permit or reapply for a new permit.

      ______________________________

      APPLICANT'S SIGNATURE

      APPROVAL

      This permit is granted on __________(Date) to perform those activities noted above, and will expire__________(1 yr. max. from date of issue)

      The permittee is limited to perform these activities__________times or during the tenure of the permit, subject to the conditions noted below. This permit is not transferable.

      ______________________________

      ISSUING AUTHORITY

      Restrictions:

      Distribution:

   4. (1) Permittee
   5. (2) Issuing Authority
   6. (3) Division of Law Enforcement, Department of Justice, P.O. Box 13387, Sacramento, CA 95813

   7. (4) Chief fire authority where explosives to be stored or used.

      * Terminal Approvals shall be forwarded to: Enforcement Services Division California Highway Patrol, P.O. Box 898, Sacramento, California 95804

   How and/or where stored

   How and/or where used

   I, the undersigned, certify that I understand and will abide by all Federal, State and local laws, ordinances, rules or orders to perform those acts noted herein. I also understand that all unused inventory covered by the permit on or before the expiration date will be disposed of in the following manner:

The application and permit for explosives shall contain all the information on the following form and such other information as may be required by the issuing authority.

NAME AND ADDRESS OF ISSUING AUTHORITY (See Section 12007 Health and Safety Code)

APPLICATION AND PERMIT--EXPLOSIVES

Application & Permit No.

Application Date

Fee: $2.00 100 lbs. or less

Permit Date

$10.00 more than 100 lbs.

(Min. 7 day waiting period)

Note: Authority cited: Section 12081, Health and Safety Code. Reference: Sections 12000-12401 inclusive, Health and Safety Code.

History

1. Amendment filed 11-4-77; effective thirtieth day thereafter (Register 77, No. 45). For prior history, see Register 71, No. 5.