657-17-182JB - SPECIFICATIONS_Part5b.pdf

MISSOURI DEPARTMENT OF NATURAL RESOURCES

AIR POLLUTION CONTROL PROGRAM

P.O. BOX 176, JEFFERSON CITY, MO 65102-0176

ASBESTOS PROJECT NOTIFICATION

MO 780-1226 (5-05)

FOR APCP USE ONLY

PART B. CONTRACTOR INFORMATION AND AUTHORIZATION

10a.I CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF FEDERAL REGULATION (40 CFR PART 61 SUBPART M) WILL BE ON-SITE DURING THE PROJECT AND PROOF THAT THIS PERSON HAS COMPLETED THE REQUIRED TRAINING WILL BE

AVAILABLE FOR INSPECTION BY THE DEPARTMENT.

10b.BY MY SIGNATURE, I ATTEST THAT ALL ASBESTOS ABATEMENT PROCEDURES SHALL BE PERFORMED IN COMPLIANCE WITH

ALL APPLICABLE STATE AND FEDERAL REGULATIONS.

10c. I HEREBY CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND UNDERSTANDING, THE INFORMATION PROVIDED IN THIS

NOTIFICATION IS TRUE AND CORRECT.

DATE RECEIVED CHECK DATE

CHECK NUMBER CHECK AMOUNT

*NOTE: A NON-REFUNDABLE REVIEW FEE OF $100 MUST BE SUBMITTED FOR ANY ASBESTOS ABATEMENT PROJECT INVOLV- ING 160 SQUARE FEET, 260 LINEAR FEET, 35 CUBIC FEET, OR MORE OF FRIABLE ASBESTOS-CONTAINING MATERIAL, AND FOR PLANNED RENOVATION PROJECTS AS DEFINED IN U.S. EPA REGULATION 40 CFR PART 61 SUBPART M.

**THIS NOTIFICATION DOES NOT SATISFY THE REQUIREMENT FOR DEMOLITION NOTIFICATION. USE FORM NUMBER 780-1923

FOR DEMOLITION NOTIFICATION.

MAKE CHECKS PAYABLE TO MISSOURI AIR POLLUTION CONTROL PROGRAM OR THE APPROPRIATE LOCAL AGENCY.

PART A. NOTIFICATION INFORMATION

1. TYPE OF NOTIFICATION (CHECK ONE)

ORIGINAL REVISION CANCELLATION

2. TYPE OF PROJECT NOTIFICATION

160 SQUARE FEET, 260 LINEAR FEET, 35 CUBIC FEET OR MORE OF FRIABLE ASBESTOS MATERIAL INVOLVED* LESS THAN 160 SQUARE FEET, 260 LINEAR FEET, OR 35 CUBIC FEET OF FRIABLE ASBESTOS MATERIAL INVOLVED

DOES THIS PROJECT INVOLVE STRUCTURAL RENOVATION OR DEMOLITION **

3. IF AN UNSAFE STRUCTURE IS BEING DEMOLISHED UNDER THE ORDER OF A STATE OR LOCAL GOVERNMENT AGENCY, INCLUDE A COPY OF THE UNSAFE BUILDING DECLARATION AND COMPLETE THE FOLLOWING:

A. NAME OF INDIVIDUAL ORDERING DEMOLITION B. TITLE

C. AUTHORITY OF THE INDIVIDUAL D. TELEPHONE NUMBER

A. DATE AND HOUR OF THE EMERGENCY

B. DESCRIPTION OF THE SUDDEN, UNEXPECTED EVENT

C. EXPLANATION OF HOW THE EVENT CAUSED UNSAFE CONDITIONS OR WOULD CAUSE EQUIPMENT DAMAGE OR AN UNREASONABLE FINANCIAL BURDEN

4. FOR EMERGENCY RENOVATIONS COMPLETE THE FOLLOWING:

5. IF A WAIVER OF ANY REQUIREMENT IS REQUESTED, INDICATE THE WAIVER DESIRED AND THE JUSTIFICATION FOR SUCH A

WAIVER. (USE SUPPLEMENTAL SHEET IF NECESSARY)

A. WAIVER B. JUSTIFICATION

1. ASBESTOS ABATEMENT CONTRACTOR NAME

2. CONTRACTOR ADDRESS

3. CITY 4. STATE 5. ZIP CODE

6. MISSOURI REGISTRATION NUMBER 7. REGISTRATION EXPIRATION DATE

8. ON-SITE PROJECT SUPERVISOR AND CERTIFICATION NUMBER 9. CONTRACTOR TELEPHONE NUMBER

11. SIGNATURE 12. DATE

13. PRINTED NAME AND TITLE

PART C. PROJECT DESCRIPTION

1. DESCRIPTION AND QUANTITY OF FRIABLE ASBESTOS MATERIALS TO BE DISTURBED

PART D. ASBESTOS MATERIALS TO BE DISTURBED

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

2. DESCRIPTION AND QUANTITY OF NON-FRIABLE ASBESTOS MATERIALS TO BE DISTURBED

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

MATERIAL SQUARE FEET LINEAR FEET CUBIC FEET

3. DESCRIBE THE PROCEDURE USED FOR THE DETECTION OF ASBESTOS CONTAINING MATERIALS INCLUDING THE ANALYTICAL METHOD EMPLOYED. INCLUDE A COPY OF THE ASBESTOS

INSPECTION REPORT.

MO 780-1226 (5-05)

1. FACILITY/PROJECT NAME

2. ADDRESS

3. PROJECT CITY 4. COUNTY 5. STATE 6. ZIP CODE

7. OWNER NAME

8. OWNER ADDRESS

9. OWNER CITY 10. STATE 11. ZIP CODE

12. OWNER CONTACT 13. OWNER TELEPHONE NUMBER

14. BUILDING SIZE 15. NUMBER OF FLOORS 16. AGE IN YEARS

17. PRESENT USE 18. PRIOR USE

PART E. PROJECT SCHEDULE

PART F. OTHER MISSOURI CERTIFIED PERSONNEL INVOLVED WITH PROJECT

1. SITE PREPARATION PHASE

2. ASBESTOS ABATEMENT PHASE

3. DAILY WORK SCHEDULE

START DATE COMPLETION DATE TIME

START DATE COMPLETION DATE TIME

START TIME QUIT TIME LUNCH BREAK

DISCIPLINE

1. AIR SAMPLING

PROFESSIONAL

2. INSPECTOR

3. MANAGEMENT

PLANNER

4. PROJECT

DESIGNER

NAME CERTIFICATE

NUMBER TELEPHONE

PART G. PROJECT DESCRIPTION

PART H. WASTE DISPOSAL

1. DESCRIBE ABATEMENT WORK INCLUDING LOCATION IN BUILDING, PLANNED DEMOLITION/RENOVATION, AND METHODS TO BE USED

2. DESCRIBE WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS OF ASBESTOS

3. DESCRIBE THE CONTINGENCY PLAN IF UNEXPECTED RACM IS DISCOVERED

MO 780-1226 (5-05)

1. NAME OF WASTE TRANSPORTER

2. ADDRESS

3. CITY 4. STATE 5. ZIP CODE

6. CONTACT PERSON 7. TELEPHONE NUMBER

8. WASTE DISPOSAL SITE

9. ADDRESS

10. CITY 11. STATE 12. ZIP CODE

13. CONTACT PERSON 14. TELEPHONE NUMBER

PART I. SUPPLEMENTAL INFORMATION

1. PROJECT SITE 2. NOTIFICATION DATE

3. PART NUMBER 4. ITEM NUMBER

MO 780-1226 (5-05)