Form 5600-PM-BMP0021 "Blasting Activity Permit" - Pennsylvania

What Is Form 5600-PM-BMP0021?

This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Pennsylvania Department of Environmental Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 5600-PM-BMP0021 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Environmental Protection.

ADVERTISEMENT
ADVERTISEMENT

Download Form 5600-PM-BMP0021 "Blasting Activity Permit" - Pennsylvania

1028 times
Rate (4.5 / 5) 51 votes
5600-PM-BMP0021
Rev. 6/2018
COMMONWEALTH OF PENNSYLVANIA
Permit Number:
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Municipality:
BUREAU OF MINING PROGRAMS
Issue Date:
Auth I.D.:
BLASTING ACTIVITY PERMIT
In accordance with the provisions of the Administrative Code of 1929 (Section 1917-A) and 25 PA Code Chapter 211.
1.
Name and description of project
2.
Applicant
2(a)
Blasting Contractor Information
Name:
Blasting contractor Yes
No
If yes,
Address:
Name:
E-mail
Address:
Type of Business
Telephone:
Telephone:
Applicant Authorized Representative/Title
Applicant Authorized Representative (signature)
2(b)
ATF Lic./Permit Name and Number.
Emergency Contact
Name:
Title:
Phone:
3.
Duration and Times of Blasting Activity
Blasting activity end date
Anticipated days of the week and times when blasting may occur
Days
thru
Time
AM or
PM thru
AM or
PM
4.
Location of Blasting Activity
Municipality/Township
County:
Map (attachment)
Lat.:
Long.:
5.
Proof of Insurance Certificate (attachment)
6.
Dwellings, Structures and Utilities
Indicate distance and direction (in degrees) to the nearest building, neither owned nor leased by the permittee,
from the area where blasting will occur
feet/
degrees. Indicate method that will be employed to
satisfy the requirements of Chapter 211 Subchapter G (relating to monitoring requirements)
Will blasting be conducted within 200' of an underground utility line (see § 211.182).
Yes
No
Will blasting be conducted within 800' of any public road?
Yes
No
If yes, what precautions will be taken to protect the public?
- 1 -
5600-PM-BMP0021
Rev. 6/2018
COMMONWEALTH OF PENNSYLVANIA
Permit Number:
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Municipality:
BUREAU OF MINING PROGRAMS
Issue Date:
Auth I.D.:
BLASTING ACTIVITY PERMIT
In accordance with the provisions of the Administrative Code of 1929 (Section 1917-A) and 25 PA Code Chapter 211.
1.
Name and description of project
2.
Applicant
2(a)
Blasting Contractor Information
Name:
Blasting contractor Yes
No
If yes,
Address:
Name:
E-mail
Address:
Type of Business
Telephone:
Telephone:
Applicant Authorized Representative/Title
Applicant Authorized Representative (signature)
2(b)
ATF Lic./Permit Name and Number.
Emergency Contact
Name:
Title:
Phone:
3.
Duration and Times of Blasting Activity
Blasting activity end date
Anticipated days of the week and times when blasting may occur
Days
thru
Time
AM or
PM thru
AM or
PM
4.
Location of Blasting Activity
Municipality/Township
County:
Map (attachment)
Lat.:
Long.:
5.
Proof of Insurance Certificate (attachment)
6.
Dwellings, Structures and Utilities
Indicate distance and direction (in degrees) to the nearest building, neither owned nor leased by the permittee,
from the area where blasting will occur
feet/
degrees. Indicate method that will be employed to
satisfy the requirements of Chapter 211 Subchapter G (relating to monitoring requirements)
Will blasting be conducted within 200' of an underground utility line (see § 211.182).
Yes
No
Will blasting be conducted within 800' of any public road?
Yes
No
If yes, what precautions will be taken to protect the public?
- 1 -
5600-PM-BMP0021
Rev. 6/2018
7.
Blast Loading Plan
MAX
MAX
BURDEN
SPACING
HOLE DEPTH
STEMMING
Hole
#
#
DIA.
HOLES
ROWS
MIN.
MAX.
MIN.
MAX.
MIN.
MAX.
MIN.
TYPE
A
B
C
D
E
Maximum explosives weight per delay (less than 8ms)
Minimum Scaled Distance
Specific Type(s) of Explosives
Method of blast initiation
Electric
Non-Electric
Electronic
Other
Explain Other
Comments:
A
B
C
D
E
- 2 -
5600-PM-BMP0021
Rev. 6/2018
8.
Blast Loading Plan
MAX
MAX
BURDEN
SPACING
HOLE DEPTH
STEMMING
Hole
#
#
DIA.
HOLES
ROWS
MIN.
MAX.
MIN.
MAX.
MIN.
MAX.
MIN.
TYPE
A
B
C
D
E
Maximum explosives weight per delay (less than 8ms)
Minimum Scaled Distance
Specific Type(s) of Explosives
Method of blast initiation
Electric
Non-Electric
Electronic
Other
Explain Other
Comments:
A
B
C
D
E
- 3 -
5600-PM-BMP0021
Rev. 6/2018
Limits on Peak Particle Velocity and Airblast
9.
Blasts shall be designed and conducted to achieve either a minimum scaled distance of 90 or meet the maximum
allowable peak particle velocity indicated by Figure 1 of PA Code Chapter 211.151 (c) and not exceed the noise
levels specified in Table 1 of PA Code Chapter 211.151 (d) at the closest building not owned or leased by the
permittee or its customer.
The Department may establish an alternative peak particle velocity or airblast level if it determines that an
alternative standard is appropriate. Request for the Department to establish an alternative peak particle velocity
or airblast level must be submitted to the Department Blasting and Explosives Inspector in writing. (attachment)
NOTE: Additional review time will be necessary if the applicant requests that the Department establish an
alternative peak particle or airblast limit.
DEPARTMENT USE ONLY
Alternative Maximum Allowable Peak Particle Velocity
Alternative Maximum Allowable Airblast
10.
Permits to Store Explosives
Will explosives be stored within the proposed blasting activity area? Yes
No
If "yes" provide current explosives storage security plan number
If no explain the disposition of explosives materials used for this project
11.
Prepared by:
Name
Blaster's License BL#
Signature:
ALL BLASTING ACTIVITIES SHALL BE CONDUCTED IN ACCORDANCE WITH THE BLASTING ACTIVITY PERMIT
EXCEPT AS MODIFIED BY ANY TERMS AND CONDITIONS ATTACHED HERETO. UPON RECEIPT OF THIS
AUTHORIZATION BLASTING ACTIVITIES MAY COMMENCE. THIS AUTHORIZATION IS VALID FOR BLASTING
ACTIVITIES CONDUCTED NECESSARY FOR THE COMPLETION OF THE PROJECT IDENTIFIED AND NAMED IN
SECTION 1 OF THIS PERMIT.
DEPARTMENT USE ONLY
Blasting and Explosives Inspector
ID #
Based on the information provided by the
applicant the blasting activities proposed in this
application can be conducted in accordance with
Recommended
Pa.
Code
Chapter
211.
Signature
Approval Yes
No
Date
For the Department
Name
Title
Signature
Approval Yes
No
Date
Comments:
- 4 -
Page of 4