NAME:          ____________________________________________________
 

ADDRESS:            _____________________________________________________________
 

LOCATION OF CONTROL BURN:  __________________________________________
 

DATE & TIME OF CONTROL BURN:            _________________________________
 

CONTACT NUMBER FOR PERSON CONDUCTING BURN:_________________

I understand that this notification in no way absolves me from any regulations regarding open air burning as referenced in the Code of Virginia and the Franklin County Code.  I certify that I will be conducting this open air burn in accordance with the previously stated laws and that I may be responsible for any damages or costs incurred as a result of this open air burn.

______________________________________            ______________________________
           Signature of Applicant                                                                   Date

This form can be faxed to the Franklin County Department of Public Safety at 540-483-3086 during normal business hours which are Monday through Friday from 8:00 AM until 4:30 PM.  All other times and during Holidays when the administrative office of Public Safety is closed, please fax this form to the Franklin County Communications Center at 540-483-3023.