Modoc County Ag Pass

✻ = Required

First Name ✻

Last Name ✻

Ranch/Business Name ✻

Mailing Address ✻

City ✻

State ✻

Zipcode ✻

Email ✻

Cell Phone ✻

Date of Birth (mm/dd/yy) *Applicants must be 18 by training date 12/31/23 to participate in the ag pass program this year. ✻

Commercial Livestock Operation ✻

I attest that I am a commercial livestock operator for the purpose of this program, defined as having more than 50 head of cattle or 5 bee hives.

Conditional Access with Livestock Pass ✻

I understand that decisions for access can rapidly change during a fire or other natural disaster and will be dependent on safety conditions at the time and upon approval of emergency personnel.

Insurance and Risk ✻

I understand access in an area closed to the public during a disaster may affect the coverage of my property liability insurance, vehicle or equipment insurance and worker’s compensation coverage. Program administrators, collaborators and trainers shall not be liable for injury or death of someone participating in activities resulting from the inherent risk of re-entering damage areas to feed, water and medically treat livestock.

Violations of Pass ✻

I understand the utilization of the pass is to care for commercial livestock within the evacuation zone. Thus, if you are found outside of the scope of commercial livestock pass your pass may be permanently revoked.

Liability ✻

I understand program administrators, collaborators and trainers shall not be liable for injury or death of someone participating in activities resulting from the inherent risk of re-entering damage areas to feed, water, transport and medically treat livestock.

Training and Contingency ✻

I understand that the pass will be contingent upon county review and will require participation in approval of mandatory training

Additional family and employees for training: Please provide first name, last name, birthdate and email for all additional drivers who will be participating in the training.

(THERE WILL BE NO ADDITIONAL GUESTS ALLOWED AT TRAINING, ONLY THOSE WHO ARE PRE-REGISTERED)

I have obtained an Ag Pass in another County. Specify County ✻

Yes No

Provide County(ies)

I have received qualified training from another source. Examples include: Incident Safety Awareness for Hire Vendors (Operator’s Training), Basic 32 or FFT1 Training, ICS-100 + S-190, RT-130, Volunteer Fire Fighter Certification, UC Cooperative Extension Ag Pass Training, or Other (provide detail). Documentation will be required for proof. ✻

Yes No

Training Details

Livestock Location - Please provide description or APN, Season of use, livestock description for all Modoc County sites.

EXAMPLE 1: Bear Mountain Allotment 001-222-333, Year-Round, 75 head of cattle and 20 sheep

EXAMPLE 2: 111-222-444, 111-222-443, 111-222-445, Nov.-May, 250 head of cattle

EXAMPLE 3: 60 bee hives 111-222-3333 November-April, 25 bee hives 222-333-444 April-September and 35 bee hives 555-222-111 April-September. ✻

Cattle Operators - You must answer ALL questions in this section

Cattle Brand(s) # (e.g. A 072750):

https://www.cdfa.ca.gov/AHFSS/Livestock_ID/2010_Brand_Book.html.

CATTLE - Other Identifiable Livestock Markings including ear tags, ear notches, etc. (copy)

Bee Operators - You must answer ALL questions in this section

Are you a registered beekeeper in Modoc County?

Yes No

Bee - Other Identifiable Hive markings such as brands, hive color, etc. etc.

Information Sharing

Information shared on this form will be used to create a database maintained and updated by Modoc County Agricultural Department and UC Cooperative Extension. Data will be available to key agencies. ✻

I understand my information will be shared, I am voluntarily completing this form.

** To the best of my knowledge, the information entered above is true and correct. **

Please type name - ✻

Other Information