A8+-+SFN17987.pdf

ASBESTOS NOTIFICATION OF DEMOLITION AND RENOVATION

NORTH DAKOTA DEPARTMENT OF ENVIRONMENTAL QUALITY

DIVISION OF WASTE MANAGEMENT

SFN 17987 (9-2021)

I. Type of Notification THIS NOTICE MUST BE SUBMITTED 10 WORKING DAYS BEFORE BEGINNING THE ACTIVITY

Original Revised Cancelled Date:

II. Type of Operation III. Is Asbestos Present?

Demolition Renovation Ordered Demolition Emergency Renovation Yes No

IV. Dates of Asbestos Removal (MM-DD-YY) V. Dates of Demolition or Renovation (MM-DD-YY)

Start: Stop: Start: Stop:

VI. Facility Information (identify owner and operator, if applicable)

Owner Name

Owner Address City State ZIP Code

Contact Person Email Telephone Number

Operator (if different than owner)

Operator Address City State ZIP Code

Contact Person Email Telephone Number

VII. Facility Description (include building name, number and floor or room number)

Building Name

Building Address City State Zip Code County

Site Location (floor or room number(s))

Building Size (Sq. Ft.) Number of Floors Age of Building/Year Built

Present Use Prior Use

VIII. Asbestos Contractor (If applicable, please enter Demolition or Renovation Contractor information on page 2)

Contractor Name ND License Number

Contractor Address City State ZIP Code

Contact Person Telephone Number

IX. Asbestos Inspector

Firm Name ND License Number

Firm Address City State ZIP Code

Name of Inspector Telephone Number

X. Approximate Amount of Asbestos, Including:

Regulated Asbestos-

Containing Material

(RACM)

to be Removed

Nonfriable Asbestos-Containing Material to be Removed

Nonfriable Asbestos-Containing Material not to be Removed

Category I Category II Category I Category II

Pipe (Linear Ft.)

Surface Area (Sq. Ft.)

Volume from Facility Component(s)

(Cu. Ft.)

SFN 17987 (3-2019) - Page 2

XI. Testing Procedure for Determining Asbestos and Type of Asbestos Material(s)

PLM TEM Other:

Type of Asbestos-Containing Material(s)

XII. Description of Work Practices and Engineering Controls to Prevent Asbestos Emissions (check all that apply)

Adequately Wet Materials Glove Bag Seal in Leak Tight Containers Encapsulate Negative Air Containment Seal in Leak Tight Wrapping Mini-enclosure Other:

XIII. Description of Planned Demolition or Renovation Work (backhoe, bulldozer, hand removal, etc.)

Will the Facility or Facility Debris be Burned?

Yes No If yes, you must contact your local Health Unit or the Waste Management Division at 701.328.5166, to complete an Open Burn Variance Application: SFN 8509.

XIV. Demolition Contractor

Firm Name Secretary of State License Number

Firm Address City State ZIP Code

XV. Waste Transporter

Name Waste Hauler Permit Number

Address City State ZIP Code

XVI. Waste Disposal Site for Asbestos-Containing Materials

Name Permit Number Telephone Number

Address City State ZIP Code

Will the waste be disposed of at a site other than a Landfill approved for asbestos? Yes No

If yes, you must contact the Waste Management Division at 701.328.5166 to complete an Inert Waste Disposal Variance Application: SFN 50278.

XVII. Waste Disposal Site for Demolition or Renovation Materials (other than asbestos)

Name Permit Number Telephone Number

Address City State ZIP Code

XVIII. If Demolition was Ordered by Government Agency, Identify the Agency and Attach a Copy of the Order

Authority/Agency Date of Order (MM/DD/YY) Telephone Number

XIX. Emergency Demolition or Renovation

Is this an emergency demolition or renovation? Yes No If yes, you must contact the Department at 701.328.5166.

XX. Description of Procedures to be Followed in the Event of an Unexpected Asbestos Fiber Release

XXI. General Comments

XXII. I certify to the best of my knowledge that the above information is true and correct. I further certify that all asbestos abatement work on this project will be performed by individuals certified in accordance with the North Dakota Air Pollution Control Rules 33.1-15-13.

Signature of Owner/Operator Print Name Date

Business/Organization Telephone Number

(701)328-5166 (701)328-5200 - fax (If faxing, original copy must be mailed with valid signature)

Return form to: North Dakota Department of Environmental Quality Division of Waste Management

4201 Normandy Street, 2nd Floor Bismarck, ND 58503-1324

SFN 17987 (3-2019) - Page 3

INSTRUCTIONS FOR COMPLETING THE

ASBESTOS DEMOLITION AND RENOVATION NOTIFICATION FORM

GENERAL INFORMATION

The Asbestos NESHAP, Section 33.1-15.1-13-02 of the North Dakota Air Pollution Control Rules, requires written notification of demolition or renovation activities in facilities under Subsection 02.6. In most cases, a facility includes all types of structures except single family homes and apartment buildings having no more than four units. The enclosed form must be used to fulfill this requirement. Only complete notification forms will be accepted.

The notification should be typewritten or neatly printed and postmarked or delivered no later than ten working days prior to the beginning of either the asbestos removal activity (Section IV) or demolition activity (in Section V) whichever is applicable.

INSTRUCTIONS

I. Type of Notification: Check "Original" if the notification is a first time or original notification," Revised" if the notification is a revision of a prior notification, or "Canceled" if the activity has been canceled. On the right side enter the date that the notification is being submitted.

II. Type of Operation: Check as appropriate for facility demolition, for facility renovation, for ordered demolitions, or for emergency renovations.

III. Is Asbestos Present? Answer "Yes" or "No."

IV. Scheduled Dates of Asbestos Removal (MM-DD-YY): Enter scheduled dates (month/day/year) for asbestos removal work. Asbestos removal work includes any activity, including site preparation, which may break up, dislodge or disturb asbestos material.

V. Scheduled Dates of Demolition/Renovation (MM-DD-YY): Enter scheduled dates (month/day/year) for beginning and ending the planned demolition or renovation project.

VI. Facility Information: Enter the names, addresses, contact persons and telephone numbers of the following:

Owner: Legal owner of the site at which asbestos is being removed or demolition planned.

Operator: Demolition contractor, general contractor, or any other person who leases, operates, controls or supervises the site.

If known, the name of the site supervisor should be entered as the contact person for the notification. If additional parties share responsibility for the site, demolition activity, renovation or ACM removal, include complete information (including name, address, contact person and telephone number) on additional sheets submitted with the form.

VII. Facility Description: Provide the following information on the areas being renovated or demolished:

Building Address: Physical location of site.

Building Size: The building size in square feet.

Number of Floors: Enter the number of floors including basement, if applicable.

Year Facility was Built or Age: Enter approximate age of the facility.

Present Use/Prior Use: Describe the primary use of the facility or enter the following codes: H -- Hospital; S -- School; P -- Public Building; O -- Office; I -- Industrial; U -- University or College; C -- Commercial; or R -- Residence.

VIII. Asbestos Contractor: Name and address of contractor hired to remove asbestos.

IX. Asbestos Inspector: The firm who conducted the asbestos inspection prior to demolition/renovation.

SFN 17987 (3-2019) - Page 4

X. Approximate Amount of Asbestos Including: (1) Regulated ACM to be removed (including nonfriable ACM to be sanded, ground or abraded); (2) Category I and Category II nonfriable asbestos containing material (ACM) to be removed; and (3) Category I and Category II nonfriable asbestos containing material not to be removed. For both renovations and demolitions, enter the amount of RACM to be removed by entering a number in the appropriate box. If applicable, enter the amount of nonfriable ACM to be removed during a demolition or renovation, and/or enter the amount of nonfriable ACM not to be removed during a demolition or renovation.

Category I nonfriable material includes packing, gaskets, resilient floor covering and asphalt roofing materials. Category II nonfriable material includes any material, excluding Category I materials, that when dry, cannot be crumbled, pulverized or reduced to powder by hand pressure, or mechanical forces expected to operate on the material during the demolition or renovation activity. All Category II materials must be removed prior to demolition.

Complete the volume from facility component(s) if asbestos-containing materials have been removed from facility components and the volume is known.

XI. Asbestos Testing Procedure and Type of Asbestos Materials Present: Check the appropriate box for the procedure that was used to determine asbestos content. Also, describe the kinds of asbestos-containing materials that are present.

XII. Description of Work Practices and Engineering Controls to Prevent Asbestos Emissions: Check the appropriate box(s) for work practices that will be employed to prevent asbestos emissions.

XIII. Description of Planned Demolition or Renovation Work: Include a brief description of the renovation/demolition technique(s) to be used. Also, indicate if the facility or facility debris will be burned.

XIII. Demolition or Renovation Contractor: Name and address of contractor hired to perform demolition or renovation work.

XV. Waste Transporter(s): Enter the name(s), addresses(s), contact person(s) and telephone number(s) of the person(s) or company(ies) responsible for transporting ACM from the removal site to the waste disposal site. If the removal contractor or owner is the waste transporter, state "same as owner" or "same as removal contractor." If multiple parties are responsible include complete information on an additional sheet and submit with this form.

XVI. Waste Disposal Site for the Asbestos-Containing Materials: Identify the waste disposal site, including the complete name, location, and telephone number of the facility. If ACM is to be disposed of at more than one site, provide complete information on an additional sheet submitted with the form. Permit number(s) must be included. If the waste will not be disposed of at a landfill approved for asbestos, then an Inert Waste Disposal Variance Application must be completed and approved by the Department.

XVII. Waste Disposal Site for Demolition or Renovation Materials: Identify the waste disposal site, including the complete name, location, and telephone number of the facility. If the waste will not be disposed of at a landfill approved for waste materials, then an Inert Waste Disposal Variance Application must be completed and approved by the Department.

XVIII. If Demolition Ordered by a Government Agency, Please Identify the Agency below: Provide the name of the responsible official, title and agency, authority under which the order was issued and the date of the order. A copy of the order from the government agency must be attached to this form.

XIX. Emergency Demolition or Renovation Information: Please identify if the work is an emergency demolition or renovation. If yes, please immediately contact the Department.

XX. Description of Procedures to be Followed in the Event that Unexpected Asbestos Fiber Release: Provide adequate information to demonstrate that appropriate actions have been considered and can be implemented to control asbestos emissions adequately, including at a minimum, conformance with applicable work practice standards. Attach an additional sheet of paper if needed and submit with this form.

XXI. General Comments: as necessary. Attach an additional sheet of paper if needed and submit with this form.

XXII. Verification and Certification: Certify the accuracy and completeness of the information provided and the intent to comply with the

North Dakota Air Pollution Control Rules by signing and dating the notification form. Please sign and print the name of the owner or operator and list the business or organization the owner or operator is affiliated with.