Voluntary Magazine Questionnaire For Agencies/Entities Who Store Explosive Materials

Page 5 of 4

OMB NO. 1140-0092 (xx/xx/xxxx)

Voluntary Magazine Questionnaire for Agencies/Entities Who Store Explosive Materials

1. Name of Agency/Entity:

_____________________________________________________________________________

2. Address of Agency/Entity:

______________________________________________________________________________

______________________________________________________________________________

2. Contact name and phone number of person(s) responsible for explosives storage:

______________________________________________________________________________

______________________________________________________________________________

4. Mailing address: ________________________________________________

(if different from question 2)

________________________________________________

E-mail Address (optional) ________________________________________________

5. Federal explosives license or permit number(s) (if applicable): _______________

6. Do you lease/own/share any explosive magazine(s)? Yes No

7. If so, how many? ________Lease ________Own _______Share _______Other (explain)

8. Please provide the following information about each magazine. Make additional copies if needed. If the magazine does not have a street address, please provide driving directions from the nearest police station or post office. Magazine ID number is the number or name you use to identify the magazine, if applicable.

A.

Magazine Type (i.e. Type 1, 2, 3, 4, 5): _____________________________________________

(See Instruction 4)

Magazine ID Number: _________________________________________________________

Magazine Location/Address: _____________________________________________

_____________________________________________

Types of Explosives ___________________________

(Examples: high explosives, low explosives, blasting agents)

Approximate amount of explosives maintained in magazine (in pounds) during a typical 30 day period? ________________

Purpose for maintaining explosives? ________________________________________________

(Examples: evidence, use as bomb technician, use in roads, avalanche control, university research, others?)

B.

Magazine Type (i.e. Type 1, 2, 3, 4, 5): _____________________________________________

(See Instruction 4)

Magazine ID Number: _________________________________________________________

Magazine Location/Address: ______________________________________________________

_____________________________________________________

Types of Explosives ___________________________

(Examples: high explosives, low explosives, blasting agents)

Approximate amount of explosives maintained in magazine (in pounds) during a typical 30 day period? ________________

Purpose for maintaining explosives? ________________________________________________

(Examples: evidence, use as bomb technician, use in roads, avalanche control, university research, others?)

C.

Magazine Type (i.e. Type 1, 2, 3, 4, 5): _____________________________________________

(See Instruction 4)

Magazine ID Number: _________________________________________________________

Magazine Location/Address: ______________________________________________________

______________________________________________________

Types of Explosives ___________________________

(Examples: high explosives, low explosives, blasting agents)

Approximate amount of explosives maintained in magazine (in pounds) during a typical 30 day period? ________________

Purpose for maintaining explosives? ________________________________________________

(Examples: evidence, use as bomb technician, use in roads, avalanche control, university research, others?)

D.

Magazine Type (i.e. Type 1, 2, 3, 4, 5): _____________________________________________

Magazine ID Number: _________________________________________________________

Magazine Location/Address: _______________________________________________

_______________________________________________

Types of Explosives ___________________________

(Examples: high explosives, low explosives, blasting agents)

Approximate amount of explosives maintained in magazine (in pounds) during a typical 30 day period? ________________

Purpose for maintaining explosives? ________________________________________________

(Examples: evidence, use as bomb technician, use in roads, avalanche control, university research, others?)

PAPERWORK REDUCTION ACT NOTICE. This request is in accordance with the Paperwork Reduction Act of 1995.

The estimate average burden associated with this collection of information is 30 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.