1. Name of Event:

2. Date & Time of Event:

3. Rain Date, If any:

4. Name of involved barge/platform:

Official Number of involved barge/platform:

5. Point of Contact for tug & barge platform, Name:
Area code and telephone number:

6. Exact location of vessel when loading fireworks:

7. Date & time of fireworks loading:

8. Time vessel( s) will transit to launch site:

9. Latitude & Longitude of launch site:

10. Give exact location of launch site:

11. Method in securing launch vessel(s) at the launch site (The Towing Vessel is Required to Stand Off During the Fireworks Display):

12. Time the launch vessel(s) will depart display site after launch:

13. Total weight of the fireworks:

14. Quantities & size of the shells (Type, Class, & Amount of Fireworks to be used):

Maximum altitude during the display:

15. Fire Department Point of Contact (Name, Phone, & Fax):

Area code and Telephone Number:

Area code and Fax Number:

16. Describe in detail provisions made with local Fire Department to supply fire fighting protection during entire event (Name of contact & Phone Number):

Contacts Name:

Area code and Telephone Number:

17. Marine Patrol Point of Contact: (Name & Phone Number) Contacts Name: Area code and Telephone Number:

18. List all permits required and received from local and state agencies:

19. Licensed Fireworks Contractor (Name, address, Zip code):

Area code and Telephone Number:

20. Responsible official for the Sponsoring Organization that can be contacted for additional information (Name, address, Zip code):

Area code and Telephone Number:

21. Fax Number: