Form 5600-FM-BMP0439 "Request for Security Access / Portal Account Blasting Activity Permit / Blasting Activity Permit by Rule" - Pennsylvania

What Is Form 5600-FM-BMP0439?

This is a legal form that was released by the Pennsylvania Department of Environmental Protection - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • 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-FM-BMP0439 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Environmental Protection.

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Download Form 5600-FM-BMP0439 "Request for Security Access / Portal Account Blasting Activity Permit / Blasting Activity Permit by Rule" - Pennsylvania

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5600-FM-BMP0439
Rev. 1/2019
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
REQUEST FOR SECURITY ACCESS / PORTAL ACCOUNT
Blasting Activity Permit / Blasting Activity Permit By Rule
1.
USER DATA
First Name:
MI:
Last Name:
Title:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Email Address (Where you want official Electronic Correspondence to be sent):
Electronic Signature Agreement
I agree that the use of my DEP GreenPort account to submit data and records to the Pennsylvania Department of
Environmental Protection (“Department”) constitutes an electronic signature. I understand that an electronic signature
occurs every time I use my account to submit data and records to the Department.
I intend to be bound by my electronic signature. I authenticate the electronic data and record and attest to the statements
contained within. I understand that my electronic signature is fully binding and has the same legal effect as an original,
handwritten signature under the Electronic Transactions Act, 73 P.S. § 2260.101. I understand that submitting another
individual’s electronic signature or attesting to false statements in an electronic record may be subject to substantial civil
and criminal penalties, including, but not limited to, 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities). If I
discover that information I have submitted is incorrect, I will notify the Department immediately.
I am responsible for any and all activities that occur by the use of my electronic signature. I agree to take the necessary
steps to protect my password and to ensure that others do not use my account to gain unauthorized access to this system.
I will immediately notify the Department upon learning that my password may have been compromised.
User Signature:
2.
SECURITY ROLE (Select one role only)
Administrative Role: ability to complete and view information on-line but unable to submit data to DEP.
Licensed Blaster: ability to complete, view and submit data on-line to DEP. Only a Licensed Blaster should have
the ability to submit data.
Blasting License Number: BL-
3.
APPLICANT INFORMATION / DEP CLIENT DATA (In order to file applications on behalf of an applicant,
please indicate applicant below. All forms must be signed by the applicant)
DEP Client ID – if known:
Name of Applicant:
Street Address:
City:
State:
Zip Code:
I hereby authorize
to submit Blasting Activity applications on behalf of
.
Applicant Signature
1
5600-FM-BMP0439
Rev. 1/2019
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF MINING PROGRAMS
REQUEST FOR SECURITY ACCESS / PORTAL ACCOUNT
Blasting Activity Permit / Blasting Activity Permit By Rule
1.
USER DATA
First Name:
MI:
Last Name:
Title:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Email Address (Where you want official Electronic Correspondence to be sent):
Electronic Signature Agreement
I agree that the use of my DEP GreenPort account to submit data and records to the Pennsylvania Department of
Environmental Protection (“Department”) constitutes an electronic signature. I understand that an electronic signature
occurs every time I use my account to submit data and records to the Department.
I intend to be bound by my electronic signature. I authenticate the electronic data and record and attest to the statements
contained within. I understand that my electronic signature is fully binding and has the same legal effect as an original,
handwritten signature under the Electronic Transactions Act, 73 P.S. § 2260.101. I understand that submitting another
individual’s electronic signature or attesting to false statements in an electronic record may be subject to substantial civil
and criminal penalties, including, but not limited to, 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities). If I
discover that information I have submitted is incorrect, I will notify the Department immediately.
I am responsible for any and all activities that occur by the use of my electronic signature. I agree to take the necessary
steps to protect my password and to ensure that others do not use my account to gain unauthorized access to this system.
I will immediately notify the Department upon learning that my password may have been compromised.
User Signature:
2.
SECURITY ROLE (Select one role only)
Administrative Role: ability to complete and view information on-line but unable to submit data to DEP.
Licensed Blaster: ability to complete, view and submit data on-line to DEP. Only a Licensed Blaster should have
the ability to submit data.
Blasting License Number: BL-
3.
APPLICANT INFORMATION / DEP CLIENT DATA (In order to file applications on behalf of an applicant,
please indicate applicant below. All forms must be signed by the applicant)
DEP Client ID – if known:
Name of Applicant:
Street Address:
City:
State:
Zip Code:
I hereby authorize
to submit Blasting Activity applications on behalf of
.
Applicant Signature
1
5600-FM-BMP0439
Rev. 1/2019
I certify that the information provided for this Request for Security Access is complete and correct to the best of my
knowledge, information, and belief. I further certify that I am an authorized officer or agent of the Applicant responsible for
submitting this Request for Security Access. I understand that the statements and information contained herein are made
subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities). If I discover that information I
have submitted is incorrect or incomplete, I will notify the Department immediately.
Signature
A signed security form is required for each person that will be utilizing the eBlasting Web Based Application to send and
receive data electronically with DEP. Please mail completed security forms to:
Bureau of Mining Programs
Rachel Carson State Office Building
P.O. Box 8461
Harrisburg, PA 17105-8461
2
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