Application for explosives magazine storage and use permit (F-0013)

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Application for explosives magazine storage and use permit

Application for explosives magazine storage and use permit

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This information is being collected for the purpose of administering and enforcing the Workers’ Safety and Compensation Act in compliance with the Access to Information and Protection of Privacy Act. If you have any questions about the collection of this information, please contact the board’s Privacy Officer at 401 Strickland St., Whitehorse, YT, Y1A 5N8 or call 867-667-5642 or 1-800-661-0443.

Mine Information

Company Name (Mine Operator)

Property Name

Mine Manager Name

Physical Address of Mine

Mailing Address

Street Number

Street Nane

City

Province/Territory

Postal Code

Country

Primary Phone Number

Secondary Phone Number

Fax Number

Name of Certified Blaster Responsible

Yukon Blaster # of Certified Blaster Responsible

Location of Magazine(s)

Latitude

Longitude

Scaled Plan of Property

Please select a file

Attach scaled plan of property showing claim names, roads, mine workings, plant area, camp area, dwellings, and magazines)

Other information about the location

Explosives Magazine

Type

Tag Number

Length (meters)

Width (meters)

Height (meters)

Maximum quantity (kg)

The most kg of explosives that will be kept in the magazine.

Distance to road or work area (meters)

How many meters is the closest road or work area

Distance from dwelling or flammable material storage area (meters)

How many meters is the nearest dwelling or flammable materials storage area

Detonator Magazine

Type

Tag Number

Length (meters)

Width (meters)

Height (meters)

Maximum quantity (units)

The most number of detonators that will be kept in the magazine.

Distance to road or work area (meters)

How many meters is the closest road or work area

Distance from dwelling or flammable material storage area (meters)

How many meters is the nearest dwelling or flammable materials storage area

Signature, consent and declaration

By checking this box, I acknowledge that electronic communication has inherent security risks, as do all forms of communication. Notwithstanding the inherent risks of electronic communication, I consent to the use of electronic methods to transmit and receive information, including confidential and personal information between the board and myself. This consent will remain in effect until written notice to revoke this authorization has been received by the board.

By checking this box I declare that the information provided is true and correct.

My Name

My Email

The Mine Manager is aware of this application

Yes No

Mine Manager’s Name

Mine Manager’s email

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