38-Doc 00 73 00 8 - Appendix C - 2700-FM-AQ0021 - Form.pdf

2700-FM-BAQ0021 Rev. 4/2025

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF ENVIRONMENTAL PROTECTION

BUREAU OF AIR QUALITY

- 1 -

ASBESTOS ABATEMENT AND DEMOLITION/RENOVATION NOTIFICATION FORM

For Official Use Only Date Received 1 Date Received 2

Postmark Date:

Project ID#:

Permit #:

Other #:

Inspector:

NOTICE: This is not a valid asbestos abatement notification for the purposes of the Asbestos Occupations Accreditation and Certification Act unless individuals and contractors have met the certification requirements as set forth in the Asbestos Occupations Accreditation and Certification Act, Act of 1990, P.L. 805, No. 194 (63 P.S. Sections 2101-2112).

REFER TO THE ATTACHED INSTRUCTIONS FOR INFORMATION AND REQUIREMENTS.

1. TYPE OF NOTIFICATION (check one): Initial Annual Notification

Revision (highlight here, and changes) Phase of Annual Notification

Postponement Cancellation

Date of Initial Notification or, if previously revised, date of last revision:

2. PROJECT LOCATION (check one):

Allegheny County City of Philadelphia Other Location in PA (specify county):

Municipality (specify):

3. FOR ALLEGHENY COUNTY AND CITY OF PHILADELPHIA PROJECTS ONLY:

A. Does this project require a permit? Yes No (If Yes is checked, a permit application must be submitted along with this notification and approved prior to the start of the project.)

B. For City of Philadelphia projects requiring a permit:

Asbestos project inspector: Certification #:

Company name:

Address:

City: State: Zip: Phone:

4. WILL ALTERNATIVE METHODS TO ANY OF THE APPLICABLE REGULATIONS BE USED? Yes No

(If Yes is checked, approval must be obtained prior to the start of the project. Please contact the appropriate DEP regional office or local government agency (see reverse of Instruction Sheet for contact list).

5. TYPE OF OPERATION (check all that apply): Abatement prior to Renovation/Demolition

Demolition Ordered Demolition Renovation Emergency Renovation Fire Training

6. FACILITY DESCRIPTION: Job No.: (see instructions)

Facility Name:

Street/Rural Address:

City: State: PA Zip Code:

Present use: Prior use:

Will the facility be occupied during the abatement activity? Yes No

Facility size in square feet: # of floors:

Age in years:

- 2 -

7. ABATEMENT CONTRACTOR:

Company name:

Email address:

Allegheny County or City of Philadelphia License # (if applicable):

Street/Rural/POB Address:

City: State: Zip:

Contact: Telephone No. (between 8:00am & 4:30pm):

8. DEMOLITION CONTRACTOR:

Company name:

Email address:

Street/Rural/POB Address:

City: State: Zip:

Contact: Telephone No. : (between 8:00am & 4:30pm)

9. FACILITY OWNER:

Owner name:

Email address:

Street/Rural/POB Address:

City: State: Zip:

Contact: Telephone No: (between 8:00am & 4:30pm)

10. FACILITY INSPECTION (required for renovation and demolition projects):

Building inspector: Certification #:

Date of inspection: Is any material assumed to be asbestos? Yes No

Procedure, including analytical method, if appropriate, used to detect the presence of asbestos material:

Building has been declared I.D. (Imminent Danger of Collapse). An asbestos investigator will be on site during demolition.

(Allegheny County or City of Philadelphia projects only)

11. IS ANY TYPE OF ASBESTOS PRESENT? Yes No If Yes, please list in #12.

12. TYPE OF ACM, DESCRIPTION & LOCATION OF MATERIAL, APPROXIMATE AMOUNT OF ACM, TYPE OF

ABATEMENT AND FINAL AIR CLEARANCE METHOD.

PROVIDE INFORMATION IN THE SPACES BELOW, THEN CONTINUE ON ANOTHER SHEET, IF NECESSARY, USING THE SAME FORMAT.

Code * Description of material

Location of material

(room/floor/area)

Amount of

ACM

Code

Code

Code

- 3 -

Code *

Type of ACM

Code **

Units

Code ***

Type of abatement

Code ****

Final Clearance

FRI - Friable ACM LF - Linear ft. REM - Removal PCM - Phase contrast microscopy NF1 – Cat I nonfriable ACM SF - Square ft. CAP - Encapsulation TEM - Transmission electron microscopy NF2 – Cat II nonfriable ACM CF - Cubic ft. CLO - Enclosure (Note: Allegheny County NON - None treats all ACM as friable)

13. Is this project regulated by NESHAP? Yes No

Is this project subject to Act 194? Yes No

14. OPERATION SCHEDULE(S) (as applicable):

A. Asbestos abatement: Start Date: Completion Date:

Daily hours of operation: am pm to am pm

Days of week (check): Mo Tu We Th Fr Sa Su

B. Demolition: Start Date: Completion Date:

Daily hours of operation: am pm to am pm

Days of week (check): Mo Tu We Th Fr Sa Su

C. Renovation: Start Date: Completion Date:

Daily hours of operation: am pm to am pm

Days of week (check): Mo Tu We Th Fr Sa Su

COMMENTS:

15. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK:

16. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO REMOVE ACM AND TO

PREVENT EMISSIONS OF ASBESTOS AT THE DEMOLITION AND RENOVATION SITE:

- 4 -

17. WASTE TRANSPORTER(S):

A. Transporter #1 name:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

B. Transporter #2 name:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

18. WASTE DISPOSAL SITE(S)

A. Landfill name: DEP permit #:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

Asbestos Containing Material? Yes No

B. Landfill name: DEP permit #:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

Asbestos Containing Material? Yes No

19. AIR MONITORING FIRM(S):

A. Company name/individual:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

B. Final clearance firm: (if different than 19A)

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

Final clearance firm was hired by (check one): Contractor Owner

Other: Explain:

20. AIR SAMPLE FIRM(S) (City of Philadelphia projects only):

A. PCM company name/individual: Certification #:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

B. TEM company name: Certification #:

Street/Rural Address:

City: State: Zip:

Contact: Telephone:

- 5 -

21. FOR EMERGENCY RENOVATIONS:

Date of emergency (mm/dd/yy): Hour of emergency: am pm

Description of the sudden, unexpected event:

Explanation of how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden as a consequence of complying with the ten (10) working day notification requirement

22. FOR ORDERED DEMOLITIONS (attach copy of order):

Government agency that ordered:

Name of individual who ordered: Title:

Date of order (mm/dd/yy): Date ordered to begin (mm/dd/yy):

23. DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND

OR PREVIOUSLY NONFRIABLE ASBESTOS MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO

POWDER:

24. PENNSYLVANIA CERTIFICATIONS/LICENSES:

Project designer: Certification #:

Contractor (Individual): Certification #:

Supervisor: Certification #:

Contractor (Firm): Certification #:

25. FEES: Initial notification for an asbestos abatement or regulated demolition or renovation project that is subject to 40 CFR

Part 61, Subpart M (relating to National Emission Standards for Hazardous Air Pollutants), or the Asbestos Occupations

Accreditation and Certification Act (Act 1990 -194) (63 P.S. §§ 2101—2112) must be accompanied by the appropriate fee:

• For projects located in all Pennsylvania counties, except Philadelphia or Allegheny – $300 (2021-2025);

$400 (2026-2030); $500 (2031). Years are calendar years. Fee payable to "The Commonwealth of Pennsylvania

Clean Air Fund" and submitted to the respective regional office.

• For projects located in Allegheny County, refer to the Asbestos and Abrasive Blasting Fee Schedule

(https://www.alleghenycounty.us/ ), search asbestos.

• For projects located in the City of Philadelphia, refer to the fee schedule at https://www.phila.gov/services/permits-violations-licenses/apply-for-a-permit/environmental-permits-and-approvals/dust-air-pollution-and-asbestos/apply-for-an-asbestos-project-permit/.

Initial notifications will not be considered complete unless accompanied by the fee.

Please provide check # https://www.alleghenycounty.us/ https://www.phila.gov/services/permits-violations-licenses/apply-for-a-permit/environmental-permits-and-approvals/dust-air-pollution-and-asbestos/apply-for-an-asbestos-project-permit/ https://www.phila.gov/services/permits-violations-licenses/apply-for-a-permit/environmental-permits-and-approvals/dust-air-pollution-and-asbestos/apply-for-an-asbestos-project-permit/ https://www.phila.gov/services/permits-violations-licenses/apply-for-a-permit/environmental-permits-and-approvals/dust-air-pollution-and-asbestos/apply-for-an-asbestos-project-permit/

- 6 -

* * * * * SIGN BOTH STATEMENTS * * * * *

26. I HEREBY CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF 40 CFR PART 61 SUBPART M (if applicable) WILL BE ON-SITE DURING THE DEMOLITION OR RENOVATION AND EVIDENCE THAT THE

REQUIRED TRAINING HAS BEEN ACCOMPLISHED BY THIS PERSON WILL BE AVAILABLE FOR INSPECTION

DURING ALL WORKING HOURS, AND I CERTIFY THAT ALL WORK WILL BE DONE IN ACCORDANCE WITH ALL

APPLICABLE FEDERAL, STATE, AND LOCAL AGENCY RULES AND REGULATIONS.

(Original Signature of Owner/Operator) (Date)

Printed Name of Owner/Operator: Title:

27. I HEREBY CERTIFY THAT THE FOREGOING STATEMENTS AND THE INFORMATION CONTAINED IN THIS

NOTIFICATION FORM ARE TRUE. THIS CERTIFICATION IS MADE SUBJECT TO THE PENALTIES SET FORTH IN

TITLE 18 PA. C.S.A. SECTION 4904 AND 35 P.S. SECTION 4009(b)(2).

(Original Signature of Owner/Operator) (Date)

Printed Name of Owner/Operator: Title:

ASBESTOS ABATEMENT AND DEMOLITION/RENOVATION NOTIFICATION FORM