Blasting Complaint Form

Complainant's Name

First

Last

Phone Number

Complainant's Address

Street Address

Address Line 2

City/Town

State/Province/Region

ZIP/Postal Code

Country

Date of Incident

Time of Incident

Location of Blasting Site

Street Address

Address Line 2

City/Town

State/Province/Region

ZIP/Postal Code

Country

Name of Blasting Company or Business

Description of Incident

Please complete the following only if you are alleging damage.

Was any property damaged as a result of the blasting in question?

Was a Pre-Blast Survey done on this property prior to the start of blasting?

Yes

Were you notified by the blasting company within 24 hours prior to the blasting?

Yes

Do you have any before or after documentation, such as pictures or video?

Yes

Pursuant to R.I.G.L 11-18-1, I declare under the pains and penalty of perjury that the statements and information provided herein are true as of the date of this complaint. I am also aware that there are significant penalties for submitting false information including fines, penalties, and imprisonment.

Yes

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