State of West Virginia

STATE OF WEST VIRGINIA DEPARTMENT OF ENVIRONMENTAL PROTECTION OFFICE OF EXPLOSIVES AND BLASTING EB-31 1/03 Revised 11/04 PRE-BLAST SURVEYOR INITIAL APPLICATION Due to limited size of each class, pre-registration is required. Application and fee must be submitted to OEB prior to attending the class.

$30.00 Application Fee (cash, company check, money order, certified check payable to OEB)

PERSONAL INFORMATION Attach copy of Name ______Last First Middle photo here for Street/PO Address: ______identification purposes. City ______State ______Zip ______How long have you been at the above residence ______. If less than one year, provide previous address:______

Telephone # ______Date of Birth______

E-Mail ______

Current Employment Information Pre-blast Surveyor Training (To be completed by OEB personnel) Company Name ______Conducted at: ______Address______Conducted by: ______Date completed: ______Phone No. ______

By my signature below, I certify that I have never been convicted of a felony. I also certify that all the information provided in this Pre-blast Surveyor application is true and accurate.

______Applicant Signature

Subscribed and sworn to before me, a Notary Public in and for ______County, in the State of

______, this ______day of ______, ______.

______Notary Signature

My Commission Expires ______

WV CODE 22-3-17(i): Any person who knowingly makes any false statement, representation or certification, or knowingly fails to make any statement, representation or certification in any application, petition, record, report, plan or other document filed or required to be maintained pursuant to this article or rules promulgated pursuant thereto, is guilty of a misdemeanor and, upon conviction thereof, shall be fined not less than one hundred dollars nor more than ten thousand dollars, or imprisoned in the county jail not more than one year, or both fined and imprisoned. EB-31 Page 2

Pre-blast Surveyors -- Qualifications for Individuals CSR1 §199-3.9

Individuals must possess a high school diploma or equivalent, provided that experience working as a pre-blast surveyor may be acceptable in lieu of the educational requirement, and complete the pre-blast surveyor training provided by the Office to be approved by the Office to conduct pre-blast surveys, provided that individuals meeting these criterion shall be approved. The Office shall not grant approval or re-approval to any person who is a convicted felon.

Complete the experience information below ONLY if you do not have a high school diploma or equivalent.

ACTIVE PRE-BLAST SURVEYORS EXPERIENCE VERIFICATION Must have 12 months experience to substitute. This section is to be completed by the supervisor (company official) providing the information. For individuals who are self employed or company owners/operators, the experience may be provided by permittees that have had pre-blast survey work preformed by the applicant. Letters of reference or experience should be attached. For those individuals who are substituting experience for the education requirements, a minimum of 12 months pre-blast surveyor experience must be documented. This experience is ONLY for grandfathering in surveyors who had the pre-blast survey work experience prior to May 9, 2001 (the effective date of 199CSR-1) and lack the minimum education requirements of section 3.9a.

Days worked performing functions specifically related to pre-blast surveys. ( ) A minimum of 240 working days constitutes 12 months experience.

This is to certify that ______has worked ______days performing specific pre-blast survey related work as described below under the direction and supervision of :

______Name of Company Name of Company Official

______Title of Company Official Signature of Company Official

______Company Telephone Number DATE

Describe experience: ______

______

If experience is from more than one company/supervisor, complete and submit additional copies of this page.

Please attach the following: 1. Photo copy of a Photo ID that verifies identity and address of applicant, and 2. High School Diploma if applicable, or documentation of a college degree will be accepted in lieu of a High School diploma.

Please send completed application, $30.00 application fee and above documents to: Department of Environmental Protection, Office of Explosives and Blasting, 601 57th Street, Charleston, WV 25304 prior to attending the class.