MoDNR Electronic Forms - Open Burn Vegetative Waste

MISSOURI DEPARTMENT OF NATURAL RESOURCES

FIELD SERVICES DIVISION

LOCATION OF BURN SITE

INSIDE CITY LIMITS
OUTSIDE CITY LIMITS

APPLICATION FOR PERMIT TO OPEN BURN VEGETATIVE WASTE

APPLICATION INFORMATION

APPLICANT NAME
COMPANY NAME
MAILING ADDRESS
CITY	STATE	ZIP CODE + 4 Postal Code Suffix
PRIMARY PHONE(HOME/OFFICE) Primary Phone Area Code Primary Phone Exchange	ALTERNATE PHONE(WORK SITE/CELL) Alternate Phone Area Code Alternate Phone Exchange	FAX Fax Area Code Fax Exchange
SITE INFORMATION
SITE NAME (SUBDIVISION OR DEVELOPMENT NAME)		COUNTY
SITE LOCATION (STREET ADDRESS)		CITY
DIRECTIONS
NAME OF INDIVIDUAL WHO WILL CONTROL THE BURN Last NAME OF INDIVIDUAL WHO WILL CONTROL THE BURN		PHONE Site Area Code Site Exchange
TYPE OF MATERIAL TO BE BURNED(must select at least one) TREE TRUNKS TREE LIMBS LEAVES BRUSH	DISTANCE TO NEAREST OCCUPIED STRUCTURE (yds)
Signed waivers from all home/business owners and/or an Air Curtain Destructor (ACD) are required when vegetative waste is to be burned within 200 yards of an occupied structure. An ACD may also be required as a special permit condition.
Will an ACD be used at this site? YES NO Are all relevant waivers attached? YES NO N/A
LAND DISTURBANCE PERMIT NUMBER(IF APPLICABLE; i.e. DISTURBED AREA > 1 ACRE) MO-R
FIRE DEPARTMENT INFORMATION
LOCAL FIRE JURISDICTION (A signature from your local fire jurisdiction is required.)		PHONE Fire Department Area Code Fire Department Phone Exchange

MO 780-1941(9-06)

After printing please submit form to the regional office serving your area.