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2. Name*
3. Street Address*
5. City*
6. State*
7. Zip Code*
9. Contact Number for Person Conducting Burn*
10. Email Address
12. Item to be Burned*
14. Location of Control Burn*
16. Latitude/Longitude
17. Date and Time of Control Burn*
    Date and Time of Control Burn

    Date and Time of Control Burn
19. CONTROL BURN NOTIFICATION
    *By typing your name, you are certifying that you have read and agree with the following statement in its entirety and agree that your typed name on this document is the legally binding equivalent to your handwritten signature. You will not, at any time in the future, repudiate the meaning of this signature or claim that this signature is not legally binding. 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 (Chapter 8). I certify that I understand that I will be conducting this open air burn in accordance with the above stated laws and that I may be responsible for any damages or costs incurred as a result of this open air burn, including the responsibility to reimburse the county for services and resources required to extinguish the fire. If you have any questions, please contact our office at 540-483-3091.
21. Signature*
22. Date*
    Date
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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

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