Asbestos_Notification_EZiolkowski_20211220.pdf

ASBESTOS 10-DAY RENOVATION / DEMOLITION NOTIFICATION FORM

Operator Project # Postmark Date Received Notification #

I. Type of Notification (check one): Original Revised Canceled

II. Facility Description Building Name: ____________________________________________________________________________________________

Address: _________________________________________________________________________________________________

City: __________________________________ State: __________ Zip Code: _____________ County: ______________

Site Location : _____________________________________________________________________________________________

Building Size (square feet): __________________________ # of Floors: ________________ Age in Years: __________

Present Use: _______________________________________ Prior Use: ___________________________________________

III. Type of Operation (check one): Demo Ordered Demo Renovation Emergency Renovation Fire Training

IV. Is Asbestos Present? (check one): Yes No

V. Facility Information Owner Name: ______________________________________________________________________________________

Address: ___________________________________________________________________________________________

City: ____________________________________________ State: _______________ Zip Code: _______________

Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________

Removal Contractor Name: __________________________________________________________________________

Address: __________________________________________________________________________________________

City: ____________________________________________ State: _______________ Zip Code: _______________

Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________

Other Operator (demolition/general): __________________________________________________________________

Address: ___________________________________________________________________________________________

City: ____________________________________________ State: _______________ Zip Code: _______________

Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________

VI. Procedure, including analytical methods, employed to detect the presence of and to estimate the quantity of RACM and Category I and Category II non-friable ACM:

VII. Approximate Amount of Asbestos Materials:

RACM to be Removed Non-friable Asbestos Material to be Removed Non-friable Asbestos Material

NOT to be Removed

Category I Category II Category I Category II

Pipes (linear feet)

Surface Area (square feet)

Facility Components (cubic feet)

VIII. Scheduled Dates Demolition or Renovation: Start: Complete:

IX. Dates for Asbestos Removal (MM/DD/YY) Start: Complete:

Days of the Week: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Hours of Operation:

ASBESTOS 10-DAY RENOVATION / DEMOLITION NOTIFICATION FORM

X. Description of planned Demolition or Renovation work to be performed and method(s) to be employed, including demolition or renovation techniques to be used and description of affected facility component s:

XI. Description of work practices and engineering controls to be used to comply with the requirements, including asbestos removal and waste handling emission control procedures:

XII. Waste Transporter #1 Name:

Address:

City: State: Zip Code:

Contact: Telephone: ( )

Waste Transporter #2 Name:

Address:

City: State: Zip Code:

Contact: Telephone: ( )

XIII. Waste Disposal Name:

Address:

City: State: Zip Code:

Contact: Telephone: ( )

XIV. Emergency Demolition (complete Item XIV only if this project is an Emergency Demo.)

1. Attach a copy of the Order to this notice.

2. Name of Authority Issuing Order: Title:

3. Authority of Order (Citation of Code):

4. Date of Order (MM/DD/YY): Date Ordered to Begin

XV. Emergency Renovation (Attach separate sheet with the following information if project is Emergency Renovation.)

1. Date and Hour of the Emergency:

2. Description of the Sudden, Unexpected Event:

3. Explanation of how the event caused unsafe conditions or equipment damage or an unreasonable financial burden.

XVI. Description of procedures to be followed in the event that unexpected RACM is found or non-friable ACM becomes crumbled, pulverized, or reduced to powder.

I certify that an individual trained in the provisions of NESHAP (40 CFR PART 61, SUBPART M) will be on -site during the Demolition or Renovation, and evidence that the required training has been accomplished by this person will be available during normal business hours.

XVII.

Signature of Owner/Operator Date Type or Print Name and Title

I acknowledge the existence of laws prohibiting the submission of false or misleading statements, and I certify that facts contained in this notification are true, accurate, and complete.

XVIII.

Signature of Owner/Operator Date Type or Print Name and Title