Free VARIANCE APPLICATION - Indiana

REGULATED EXPLOSIVE USE BLASTER OR REGULATED EXPLOSIVE USE OPERATOR LICENSE RENEWAL APPLICATION
State Form 52490 (R / 3-06) Approved by State Board of Accounts, 2006

INDIANA DEPARTMENT OF HOMELAND SECURITY Registration and Certification 302 West Washington Street, E239 Indianapolis, IN 46204 Telephone: (800)666-7784 or (317) 233-0208 www.in.gov/dhs/training/certregsection.html

Applicant Name: Last Address City: State First Telephone Number ZIP Middle Initial

Cert #

Expiration Date: E-mail

I hereby affirm under penalty of perjury that all of the information provided with this application is true and correct: Signature: _________________________________________ Date: _________________________________________

This form is used to report your continuing education activity for the three (3) year license period and will serve as the application for license renewal. To retain your license as a regulated explosive use-blaster or regulated explosive use-operator, each applicant shall submit a report of continuing education of 8 credit hours for each of the three (3) years. The period of licensure is three years from the quarter nearest the date of completion. The license may be renewed if compliance with the in-service requirement is reported prior to the expiration date and the fee is submitted with this form. Blaster-$175.00 Operator-$350.00

Subject

Instructor Signature

Hours

Date

For renewal of a licensure, the applicant shall accrue a minimum of eight (8) hours per year of continuing education in one or more of the following subjects:

(1) Explosives and related products, including the following: A. High explosives. B. Blasting agents. C. Chemical and physical properties of explosive products and appropriate product selection. (2) Detonation materials and unique product properties, and methods of use, including the following: A. Electric detonators. B. Non-electric detonators. C. Boosters and primers. D. Detonating cord. E. Detonating tube. (3) Electric detonators/special conditions, including the following: A. Required safety testing procedures. B. Approved test equipment. C. Approved blasting machines. (4) Blast layout and blasthole design, including the following: A. Geology. B. Topography. C. Burden and spacing calculations. D. Drill hole diameter and pattern placement. E. Blasthole detonation timing (5) Control of airblast, ground vibration, and flyrock, including the following: A. Seismograph equipment usage. B. Airblast monitoring and control measures. C. Scale distance calculations. D. Detonator timing sequences. E. Flyrock reduction techniques. (6) Blasting records, including the following: A. Delivery, storage, and use reports. B. Blasting log. C. Seismograph log. D. Record retention requirements. (7) Unpredictable hazards, including the following: A. Weather conditions. B. Stray current. C. Radio frequency energy. D. Misfire conditions. E. Site security and safety. (8) Applicable federal and state regulations and statutes. (9) New product and procedure technology.

REGULATED EXPLOSIVE USE BLASTER OR REGULATED EXPLOSIVE USE OPERATOR LICENSE RENEWAL APPLICATION CREDIT CARD PAYMENT Payment of the fee shall be by credit card, check or money order payable to the Indiana Department of Homeland Security and must accompany this application. If paying by credit card, please fill out the form below and mail it to the above address or fax it to 317/233-0497. The application must include payment of the license fee of Explosive Use-Blasters License - $175.00 or Explosive Use-Operators License - $350.00.
Full Name on Credit Card: _____________________________________________________________ Billing Address Street:____________________________________________________________________________ City:___________________________________ State _____________ ZIP Code _______________ Phone Number:___________________________________ Credit Card (check one): Visa MasterCard

Total amount to be charged: ____________

Account Number: _____________________________________________ Expiration Date (month/year): ______ / _______ CVV2 Number (last 3 digits of the number in the signature block on the back of the card): _________ By signing, Cardmember agrees to the obligations set forth by the Cardmember's Agreement with the issuer. ______________________________________________ Signature