Department of Environmental Protection

							EB-31R
1/06
                              Department of Environmental Protection
                               Division of Mining and Reclamation
                             Office of Explosives and Blasting


           APPROVED PRE-BLAST SURVEYOR RENEWAL
                       APPLICATION

Surveyor Number:

Name:

Has home address changed from original application?        Yes         No
If Yes, provide new address:




Has current employer changed since original application?       Yes          No
If Yes, provide employer name and address:




Have you completed Pre-Blast Surveys in the last 3 years?         Yes       No
If Yes, provide detailed ongoing experience that identifies the type of surveys and amount
of time performing surveys in the last 3 years.




By my signature below, I certify that I have never been convicted of a felony. I also certify
that all the information provided on this form is true and accurate.


Signature of Surveyor:

The application must be returned in person or arrangements must be made with the office to take
a photo in order to renew your surveyor approval. Office of Explosives and Blasting is located
at 601 57th Street SE, Charleston, WV 25304. Contact 304-926-0499 ext. 1500 for assistance.