Attachment_3_-_Michigan_EGLE_and_MI_LARA_Notification_of_Intent_to_Renovate-Demolish_Notificatio.pdf

(continued on reverse side)

NOTIFICATION OF INTENT TO RENOVATE/DEMOLISH

MICHIGAN DEPARTMENT OF ENVIRONMENT, GREAT

LAKES, AND ENERGY (EGLE) AIR QUALITY DIVISION

NESHAP, 40 CFR Part 61, Subpart M

MICHIGAN DEPARTMENT OF LICENSING AND

REGULATORY AFFAIRS (LARA), ASBESTOS PROGRAM,

P.A. 135 OF 1986, AS AMENDED, Section 220 (1-4) or (8)

/ Rec’d Date / /

/ Valid No.

EGLE/LARA USE ONLY

Postmark Date /

Emergency Date /

OK Send Def Ltr. Date of Def Ltr. / /

FOLLOW UP / / Spoke w/ Comments:

Notification No. Trans No.

3. ABATEMENT CONTRACTOR: Internal Project #:

Name:

Mailing Address:

City/State/Zip:

E-mail:

Contact: Phone:

4. DEMOLITION CONTRACTOR: Internal Project #:

Name:

Mailing Address:

City/State/Zip:

E-mail:

Contact: Phone:

Calculate LARA Asbestos Project Fee: (1% Project Fee) Total Project Cost: x 0.01 = Type of Contractor: License No.:

Licensing Authority:

5. FACILITY OWNER: (“Facility” includes Bridges) Name:

Mailing Address:

City/State/Zip:

E-mail:

Contact: Phone:

1. NOTIFICATION:

Date of Notification:

Date of Revision(s):

Notification Type: Original Revised Canceled Annual

Mark appropriate boxes: (both EGLE and LARA may apply):

EGLE (NESHAP) [260 ln. ft./160 sq. ft. or more is threshold] Planned Renovation – 10 working days notice Emergency Renovation Scheduled Demolition – 10 working days notice Intentional Burn – 10 working days notice Ordered Demolition

LARA (MIOSHA) [Will not accept annual notifications] Demo, Reno, Encap. (>10 ln. ft./15 sq. ft.) 10 calendar days notice Emergency Renovation/Encapsulation

6. FACILITY DESCRIPTION:

Facility Name:

Location Address/Description:

If Apt. # of units:

City/Twp. State: Zip Code:

County: Nearest Crossroad:

Size: (sq. ft.) No. of Floors: Floor No.:

Age: Present Use: Prior Use:

Specific Location(s) in Facility:

2. PROJECT SCHEDULE:

START DATE END DATE

* Renovation

+Asb. Removal

+Demolition:

Encapsulation:

Work Schedule: Please indicate the anticipated days of the week and work hours for the purpose of scheduling a compliance inspection.

Days of the Week Work Hours Asb. Removal:

Demolition:

Encapsulation:

* Includes setup, build enclosure, asbestos removal, demobilizing, etc.

+Include only those dates you are conducting asbestos removal/demo.

Check here if this is a multi-phased project, attach a schedule showing the start/end date of each phase.

7. DISPOSAL SITE:

Name:

Location Address:

City/State/Zip:

8. WASTE TRANSPORTER 1:

Name:

Address:

City/State/Zip:

Phone:

WASTE TRANSPORTER 2:

9. ORDERED DEMOLITIONS: (See NESHAP regulations for definition of “Ordered Demolition.”) A copy of the official Order must accompany this notification.

Gov’t Agency Ordering Demo:

Name/Title of Person Signing Order:

Date of Order: Date Ordered to Begin:

10. IS ASBESTOS PRESENT? Yes No To be removed prior to demolition Non-friable ACM not

Estimate the amount of asbestos: Include RACM RACM to be RACM to be removed prior to demo.

(Regulated Asbestos Containing Material) to be Removed Encapsulated Category I Category II Units of Measure removed, encapsulated, etc. Also include the amount and type (floor tile, roofing, etc.) of non-friable Category I and/or Category II ACM that will not be removed prior to demolition. (NOTE: In a demolition, cementatious ACM cannot remain in a structure, as it is likely to become regulated in the demolition/handling process. *Volume (cubic ft./meters) should be used only if unable to measure by linear/square measure It must be removed prior to demolition.) (example: asbestos has fallen off of surface).

Ln. Ft. Ln. M.

Sq. Ft. Sq. M.

Cu. Ft.* Cu.M.*

EQP5661 (rev. 04/20) MIOSHA-CSH 142 (rev. 08/15)

NOTIFICATION OF INTENT TO RENOVATE/DEMOLISH (continued)

11. PROJECT DESCRIPTION: Complete A) for Renovation (asbestos removal/encapsulation) and/or B) for Demolition:

A) RENOVATION: Mark all surfaces/types of RACM to be removed: Encapsulation (for LARA): Mark surfaces/types to be encapsulated:

Piping Fittings Boiler(s) Tanks(s) Piping Fittings Boiler(s) Tank(s) Beam(s) Duct(s) Tunnel(s) Ceiling Tile(s) Beam(s) Duct(s) Tunnel(s) Ceiling Tile(s) Mag Block Other (describe) Other (describe)

Method of removal: Describe how the asbestos will be removed from the surface (example: glove bag, scrape with hand tools, cut in sections and carefully lower, etc.):

B) DEMOLITION: Describe the method of demolition of facility, bridge, etc., and indicate if complete or partial. If partial, describe which part of facility bridge, etc., will be demolished:

12. ENGINEERING CONTROLS: Describe work practices and engineering controls used to prevent visible emissions before, during, and after removal, and until proper disposal:

13. UNEXPECTED ASBESTOS: Describe the steps you intend to follow in the event that unexpected RACM is found or previously non-friable asbestos becomes friable (crumbled, pulverized, reduced to powder, etc.) and therefore regulated:

14. PROCEDURE(S) USED TO DETECT THE PRESENCE OF ASBESTOS: A) Indicate how you determined whether or not asbestos is in the facility. If analytical sampling was used, describe method of analysis. (The determination of the presence or absence of asbestos must be made prior to submitting a renovation/demolition notification.):

B) Name, address, and phone number of company performing asbestos survey:

C) Name, accreditation number of inspector, and date of inspection:

15. EMERGENCY RENOVATIONS: Date/time of emergency: Describe the sudden, unexpected event:

Explain how the event caused unsafe conditions, and/or would cause equipment damage and/or an unreasonable financial burden:

16. I certify that an individual trained in the provisions of 40 CFR Part 61, Subpart M, will be on-site during the renovation and during demolition involving RACM above the threshold and/or during an ordered demolition. Evidence that this person has completed the required training will be available for inspection at the renovation or demolition site.

Signature of Owner or Abatement Contractor Date Signature of Owner or Demolition Contractor Date

17. Signature Requirements for Projects with Negative Pressure Enclosures: (required by LARA) Per Section 221(1)(2) of P.A. 135 of 1986, as amended, clearance air monitoring is required for any asbestos abatement project involving 10 linear feet/15 square feet or more of friable material which is performed within a negative pressure enclosure. I (the building owner or lessee) have been advised by the contractor of my responsibility under Act 135 to have clearance air monitoring performed on this project.

Signature of Building Owner or Lessee Date Signature of Asbestos Abatement Contractor Representative Date NOTE: It is not mandatory that a signed copy be sent to LARA unless requested. For affected projects, this section of the notification form must be completed, signed, and made part of your records before the project begins.

18. I certify that the above information is correct:

Printed Name of Owner/Operator Date Signature of Owner/Operator Date

MAILING ADDRESSES/PHONE NUMBERS: (See Item 1 to determine which agency requirements/regulations are applicable to your project.)

For Public Act 135 of 1986, as amended, Section 220 (1-4) or (8), mail to address below. For more info visit:

http://www.michigan.gov/asbestos

For NESHAP Demolitions/Renovations, 40 CFR, Part 61, Subpart M, please use the e-submittal process. For more information visit http://www.michigan.gov/air, under Air Links click on Asbestos NESHAP Program.

NESHAP Asbestos Program

EGLE, AQD

P.O. Box 30260 Lansing, MI 48909-7760

517.284.6777 (Office)

MIOSHA Asbestos Program

LARA, CSHD

P.O. Box 30671 Lansing, MI 48909-8171

517.284.7699 (office), 517.284.7700 (fax) http://www.michigan.gov/asbestos http://www.michigan.gov/air