WS 49 Permanent Assignment of Pyrotechnics and Repellants

Clear Form
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0335. The time required
to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

PERMANENT ASSIGNMENT OF
PYROTECHNICS AND REPELLANTS

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
WILDLIFE SERVICES
1. TYPE OF MATERIAL OR DEVICE

OMB Approved
0579-0335
EXP: XX/XXXX

2. QUANTITY

3. TOTAL VALUE

4. TARGET SPECIES

a. PYROTECHNICS
(1) SHELLCRACKERS

$

(2) WHISTLE | RACKET | SCREAMER SHELLS

$

(3) BIRD BANGER BOMBS

$

(4) BIRD BANGER ROCKETS

$

(5) BLANKS

$

(6) ROPE FIRECRACKERS

$

b. ANIMAL REPELLANT (List)
$
$
$
c. PISTOL LAUNCHER

(Temporary Assignment Only)

$

d. OTHER (List)

$
$
$

PYROTECHNICS HANDLING INSTRUCTIONS
(Read carefully)
PYROTECHNICS SHOULD BE TREATED AS POTENTIALLY DANGEROUS
We caution you in their storage and transportation. To ensure no harm to life or property, the following suggestions should be read and followed with due regard to applicable
State, local, or municipal laws or regulations.
STORAGE
When not being used, pyrotechnics should be STORED IN A SAFE AND PROTECTED PLACE away from electrical and heating lines. KEEP OUT OF REACH OF
CHILDREN! Do not expose pyrotechnics to moisture. Temporary storage of this material, such as in vehicles, should be in a tightly covered, wooden box away from gas
storage cans or other flammable materials. Pyrotechnics should not be kept loose to pick up dirt or grease that will ultimately cause fouling and improper operation of the
shotgun or pistol launcher.
USE
The use of ear and eye protection is recommended when using pyrotechnics. Launchers and pyrotechnics should be handled with extreme care to prevent accidental
injury to persons or damage to property. Pyrotechnics fired from launching pistols should slide easily into the pistol barrel. If they do not slide easily into the barrel, do not
use them. Never fire at people, buildings, or dry vegetation. The shell crackers of 12 gauge size should only be fired from a 12 gauge single-barrel gun. Damascus twistbarrel guns are unsafe for this purpose and should not be used. Guns should be cleaned following each use to prevent corrosion and to ensure safe future operation.

! ! PYROTECHNICS CAN BE DANGEROUS • THINK ABOUT USING THEM CAREFULLY ! !
The above materials or devices are accepted by me, the undersigned recipient, for use in connection with the protection of agricultural crops or other property from wildlife
depredations in _________________________________________________ County, State of _____________________________, with the express understanding that
the issuing official of the USDA APHIS Wildlife Services has not made any guarantee, representation, or warranty that the materials or devices or any part thereof are free
of any defects, latent, or patent. I do expressly understand and agree that I assume any and all risk and hazard incidental to the possession, transportation , or use of these
materials or devices, and of any and all hazards or defects therein, whether visible and known or hidden, latent, or unknown. I further agree that no claim for damages
caused to my person or property will be made by me or on my behalf arising out of the possession, transportation, or use of these materials or devices, and that I will hold
the USDA APHIS Wildlife Services or any official of this agency harmless from any and all claims for damages that may arise out of the possession, transportation, or use
of these materials or devices by me or persons under my authority. The materials or devices will be used only for abatement of depredations caused by wildlife and except
for expended materials will be returned in good condition by me to the issuing official upon request. The issuing official of the USDA APHIS Wildlife Services has provided
instruction on the safe and effective use of the materials and devices issued. I agree to comply with all Federal, State, and local laws and regulations pertaining to the use
of these materials or devices. I agree to contact local fire officials and law enforcement officials for approval prior to my use of these pyrotechnics.
5. RECIPIENT NAME AND ADDRESS (Print)

6. RECIPIENT SIGNATURE

7. DATE

The foregoing release was read by the recipient who signed in my presence after acknowledging that (s)he understood the above release.
8. ISSUING OFFICIAL NAME, ADDRESS, AND TELEPHONE NUMBER (Print)

WS FORM 49
NOV 2016

9. ISSUING OFFICIAL SIGNATURE

10. DATE

PRIVACY ACT NOTICE
5 U.S.C. 552a(e)(3) requires that each agency that maintains a system of records provide each individual from whom the agency solicits information with
the following information.
AUTHORITY FOR REQUESTING INFORMATION
7 U.S.C. 8351 to 8353, and 16 U.S.C. 667, authorizes officers, agents, and employees of the United States Department of Agriculture (USDA), Animal
and Plant Health Inspection Service (APHIS), Wildlife Services (WS) to conduct a program of wildlife services and to enter into agreements with States,
local jurisdictions, individuals, and public and private agencies, organizations, and institutions for the purpose of conducting such services.
NATURE OF YOUR DISCLOSURE OF INFORMATION
Disclosure of information solicited by USDA, APHIS, Wildlife Services is voluntary.
PRINCIPLE PURPOSE FOR WHICH THE INFORMATION IS SOLICITED
Information is solicited from you for the purpose of executing and implementing agreements for control of wildlife damage.
ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION
(1) To cooperative Federal, State, Tribal, and local government officials, employees, or contractors and other parties as necessary to carry out the
program; and other parties engaged to assist in administering the program. Such contractors and other parties will be bound by the nondisclosure
provisions of the Privacy Act. This routine use assists the agency in carrying out the program, and thus is compatible with the purpose for which the
records are created and maintained;
(2) To the appropriate agency, whether Federal, State, local, Tribal, or foreign, charged with responsibility of investigating or prosecuting a violation of

law or of enforcing, implementing, or complying with a statute, rule, regulation, or order issued pursuant thereto, of any record within this system when
information available indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and either arising by general statute
or particular program statute, or by rule, regulation, or court order issued pursuant thereto;
(3) To the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her official capacity, or any

employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee, or the United States, in
litigation, where the agency determines that litigation is likely to affect the agency or any of its components, is a party to litigation or has an interest in
such litigation, and the use of such records by the Department of Justice is deemed by the agency to be relevant and necessary to the litigation;
provided, however, that in each case, the agency determines that disclosure of the records to the Department of Justice is a use of the information
contained in the records that is compatible with the purpose for which the records were collected;
(4) For use in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when the agency, or any component
thereof, or any employee of the agency in his or her official capacity, or any employee of the agency in his or her individual capacity where the agency
has agreed to represent the employee, or the United States, where the agency determines that litigation is likely to affect the agency or any of its
components, is a party to litigation or has an interest in such litigation, and the agency determines that use of such records is relevant and necessary to
the litigation; provided, however, that in each case, the agency determines that disclosure of the records to the court is a use of the information
contained in the records that is compatible with the purpose for which the records were collected;
(5) To appropriate agencies, entities, and persons when the agency suspects or has confirmed that the security or confidentiality of information in the

system of records has been compromised; the agency has determined that as a result of the suspected or confirmed compromise, there is a risk of harm
to economic or property interests, a risk of identity theft or fraud, or a risk of harm to the security of integrity of this system or other systems or programs
(whether maintained by the agency or another agency or entity) that rely upon the compromised information; and the disclosure made to such agencies,
entities, and persons is reasonably necessary to assist in connection with the agency’s efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm;
(6) To USDA contractors, partner agency employee or contractors, or private industry employed to identify patterns, trends, or anomalies indicative of

fraud, waste, or abuse;
(7) To land management agencies, such as the Bureau of Land Management and the U.S. Fish and Wildlife Service, relating to wildlife damage on
grazing allotments;
(8) To consumer reporting agencies in accordance with 31 U.S.C. 3711(e);
(9) To Federal, State, Tribal, and local regulatory agencies and their employees and contractors who collaborate with Wildlife Services in

implementation of, or agencies that regulate, wildlife management projects or programs, or who have an interest in, or regulate, animal or public health,
or national security;
(10) To Federal or State Government-level representatives of the U.S. Environmental Protection Agency, in compliance with the Federal Insecticide,

Fungicide, and Rodenticide Act (FIFRA) mandate in 7 U.S.C. 136(f, and i thru l), of the location on a cooperator’s property where certain regulated
pesticide devices are deployed or regulated pesticides are applied; and
(11) To the National Archives and Records Administration (NARA) or to the General Services Administration for records management inspections

conducted under 44 U.S.C. 2904 and 2906.
EFFECTS OF FAILURE TO FURNISH INFORMATION
Failure to provide the solicited information will not subject you to penalties or adverse consequences.