Voluntary Magazine Questionnaire For Agencies/Entities That Store Explosive Materials

OMB 1140-0092 (XX/XX/XXXX)

Voluntary Magazine Questionnaire for Agencies/Entities That Store Explosive Materials

1. Name of Agency/Entity:

2. Address of Agency/Entity:

3. Contact Name and Phone Number of Person(s) Responsible for Explosives Storage:

4. Mailing Address (If different from Question 2.):

5. E-mail Address (Optional) :

6. Federal Explosives License or Permit Number(s) (If applicable):

7. Do You Lease/Own/Share Any Explosive Magazine(s)? Yes No

8. If so, How Many? Lease Own Share Other:

(Please explain in the space below.)

9. Please Provide the Following Information About Each Magazine (Make additional copies if needed.):

A. Magazine Type (e.g., type 1, 2, 3, 4, 5) (See Instruction 4.):

Magazine ID Number or Name (Number or name you use to identify the magazine.) (If applicable):

Magazine Location/Address (If the magazine does not have a street address, please provide driving directions from the nearest police station or post office.):

Types of Explosives (e.g., 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 (e.g., evidence, use as bomb technician, use in roads, avalanche control, university research, or other):

B. Magazine Type (e.g., type 1, 2, 3, 4, 5) (See Instruction 4.):

Magazine ID Number or Name (Number or name you use to identify the magazine.) (If applicable):

Magazine Location/Address (If the magazine does not have a street address, please provide driving directions from the nearest police station or post office.):

Types of Explosives (e.g., 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 (e.g., evidence, use as bomb technician, use in roads, avalanche control, university research, or other):

C. Magazine Type (e.g., type 1, 2, 3, 4, 5) (See Instruction 4.):

Magazine ID Number or Name (Number or name you use to identify the magazine.) (If applicable):

Magazine Location/Address (If the magazine does not have a street address, please provide driving directions from the nearest police station or post office.):

Types of Explosives (e.g., 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 (e.g., evidence, use as bomb technician, use in roads, avalanche control, university research, or other):

D. Magazine Type (e.g., type 1, 2, 3, 4, 5) (See Instruction 4.):

Magazine ID Number or Name (Number or name you use to identify the magazine.) (If applicable):

Magazine Location/Address (If the magazine does not have a street address, please provide driving directions from the nearest police station or post office.):

Types of Explosives (e.g., 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 (e.g., evidence, use as bomb technician, use in roads, avalanche control, university research, or other):

PAPERWORK REDUCTION ACT NOTICE

This request is in accordance with the Paperwork Reduction Act of 1995.This information collection is used to identify the number and locations of public explosives storage facilities (magazines), which will enable the Bureau of Alcohol, Tobacco, Firearms and Explosives personnel to respond properly to local emergencies such as natural disasters. The estimated 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, Resource Management Staff, Contracts and Forms Office, Bureau of Alcohol, Tobacco, Firearms and Explosives, 99 New York Ave, NE, 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 Office of Management and Budget control number.