Attachment_4_-_SD_Asbestos_Demolition-Renovation_Notification_Form.pdf

Asbestos Demolition/Renovation Notification Form General Information

The asbestos NESHAP, 40 CFR Part 61, Subpart M, requires written notification of demolition or renovation operations under section

61.145. This form may be used to fulfill this requirement. Only complete notification forms are acceptable. Incomplete notification may result in enforcement action.

Filling Out The Notification:

Type of Project: Put an “X” in the box that applies to your project.

Type of Notification: Put an “X” in the appropriate box.

Facility Owner: Enter the name, address and contact information for the owner of the building. If the building owner has designated a person as a contact for the project, list the designated person’s contact information and their affiliation with the building owner.

Facility Description: Enter the name, address, and county where the building is located. Also needed is the age of the building, size of the building in square feet, number of floors in the building, present use, and prior use of the building.

Asbestos Contractor: Enter the name, address, and contact information for the contractor hired to remove the asbestos-containing material.

Demolition Contractor: Enter the name, address, and contact information for the contractor hired to demolish the building.

Asbestos Transporter: Enter the name, address, and contact information for the company hired to transport the asbestos-containing material to the landfill. This area may be left blank if the asbestos contractor is also the asbestos transporter.

Waste Disposal Site: Enter the name, address, and contact information for the disposal site that will be taking any materials other than asbestos-containing materials including but not limited to debris generated from the building demolition.

Asbestos Disposal Site: Enter the name, address, and contact information for the permitted landfill that has agreed to accept the asbestos-containing waste. A list of permitted landfills is available upon request.

Description of work practices to be used: If procedures other than approved methods will be used, a detailed account of how the asbestos-containing materials will be removed is required and approval from this department required prior to any activity that will breakup, dislodge, or similarly disturb the materials occur.

Scheduled Dates of Asbestos Removal: The start date should be the first day that asbestos is planned to be disturbed. The end date is the projected finish date of the project.

Scheduled Dates of Demolition: For building demolition the start date of demolition and the projected end date will be filled in.

Regulated Asbestos-Containing Materials to be Removed: If removal of regulated asbestos-containing materials is going to take place, the amount of material to be removed needs to be listed.

Non Friable Asbestos-Containing Material: The amount and Category, Category I or II, of non friable asbestos-containing material to be removed or left in place needs to be listed. Category I includes, resilient floor coverings, gaskets, asphalt roofing products, etc.

Category II includes, transite boards or panels, asbestos cement products, etc.

Inspected By: Must be inspected by a Certified Asbestos Inspector.

Procedure(s) for Unexpected ACM: List the procedure that will be followed in the event that unexpected asbestos-containing material is encountered during a renovation or demolition procedure.

Signature of Owner/Operator: The signature of the owner or operator is required to show that the information provided is correct to the best of the person’s knowledge.

If more space is needed in any of the required fields another piece of paper or the back of the notification form can be used. If you have any questions or problems filling out the notification form, please feel free to contact the Asbestos Coordinator at 605-773-3153.

NOTIFICATION OF DEMOLITION AND RENOVATION

South Dakota

Department of Agriculture and Natural Resources

Type of Project Demolition Renovation Both Type of Notification Original Revised Courtesy Annual Cancellation Notice

Owner Name: Building Name:

Address: Address:

City: State: Zip: City: State: County: Age:

Fa ci lit y

O w ne r

Contact: Phone Number:

Fa ci lit y

D es cr ip tio n

Building Size: Num. of Floors: Present Use: Prior Use:

Contractor Name: Contractor Name:

Address: Address:

City: State: Zip: City: State: Zip:

A sb es to s C on tra ct or

Contact: Phone Number: D em ol iti on

C on tra ct or

Contact: Phone Number:

Transporter Name: Disposal Site:

Address: Address:

City: State: Zip: City: State: Zip:

A sb es to s Tr an sp or te r

Contact: Phone Number:

W as te

D is po sa l S ite

Landfill Name: Description of Work Practices to be Used: Include engineering controls to be used to prevent visible emissions.

Address:

City: State: Zip:

A sb es to s D is po sa l S ite

Scheduled Dates of Asbestos Removal: MM/DD/YY Scheduled Dates of Demolition: MM/DD/YY

Start: ___________________________ End: ____________________________ Start: ____________________________ End: ___________________________

Regulated Asbestos-Containing Material to be Removed: NonFriable Asbestos-Containing Material:

Linear Feet: _______________ Square Feet: _______________ Cubic Feet: _______________ Inspected By:

To Be Removed:

Linear Feet: ___________ Square Feet: ___________ Category I or Category II ?

To be Left in Place:

Linear Feet: ______________ Square Feet: ______________ Category I or Category II ?

Procedure(s) for Unexpected ACM: __________________________________________________________________________

IN THE EVENT THAT A BUILDING IS ORDERED DEMOLISHED BY A GOVERNMENT AGENCY, OR

EMERGENCY RENOVATIONS ARE NECESSARY, CONTACT THE ASBESTOS COORDINATOR AT 1-605-773-3153.

BY SIGNING THIS NOTIFICATION I CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF THIS REGULATION (40 CFR, PART 61, SUBPART M) WILL BE ON-SITE DURING ANY ASBESTOS ABATEMENT ACTIVITIES.

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT, AND I AM A BONA FIDE REPRESENTATIVE OF

THE ABATEMENT CONTRACTOR OR BUILDING OWNER AND HAVE AUTHORITY TO ENTER INTO

AGREEMENTS FOR MY EMPLOYER:

PRINTED NAME OF OWNER/OPERATOR SIGNATURE OF OWNER/OPERATOR DATE

FREQUENTLY ASKED QUESTIONS

For DANR use only:

ID #: Approval Signature: __________________________________ Date: ____________________

Who must submit a notification form?

Regulations require that someone (usually a contractor, property owner or consultant) submit a notification to the appropriate agency 10 weekdays* prior to disturbing any regulated asbestos-containing material (RACM) or beginning demolition. Specifically, a notification must be submitted if one of the two following situations exists:

1. It is a renovation project and at least 260 linear feet or 160 square feet or 35 cubic feet of RACM is to be removed.

2. It is a demolition project with or without asbestos-containing material (ACM).

How does a person know if a building contains asbestos material?

According to regulation prior to any work beginning in a facility an inspection must be done to determine if ACM is present, the location of the ACM, and whether the ACM is a regulated material. A person trained and certified with the State of South Dakota must conduct the inspection. Information on companies with certified persons on staff is available by calling 605-773-3153 or by accessing the asbestos homepage at https://danr.sd.gov/Environment/WasteManagement/Asbestos/default.aspx.

What is Regulated Asbestos-Containing Material?

Regulated asbestos-containing material must contain greater than one percent asbestos by weight and is:

a. Friable asbestos material

b. Category I non friable ACM that has become friable.

c. Category I non friable ACM that will be or has been subjected to sanding grinding, cutting, or abrading, or

d. Category II non friable ACM that has a high probability of becoming or has become crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the course of demolition or renovation operations regulated by this subpart.

Are there any exemptions?

Residential buildings of four or less units that remain residential property are exempt from asbestos removal and handling regulations.

Precautions should still be taken when handling ACM to reduce the risk of asbestos exposure. An informational booklet put together by the Environmental Protection Agency is available by contacting the state Asbestos Coordinator at 605-773-3153.

How are notifications submitted?

Original notifications must be sent by U.S. Mail, special delivery service, or hand-delivered to the South Dakota Asbestos Coordinator at the following address:

ASBESTOS COORDINATOR

DEPARTMENT OF AGRICULTURE AND NATURAL RESOURCES

WASTE MANAGEMENT PROGRAM

523 EAST CAPITOL AVENUE

PIERRE, SOUTH DAKOTA 57501-3182

Revisions to the original notification and courtesy notification can be sent by facsimile transmission:

Attention: Asbestos Coordinator, Waste Management Program Fax Number : 605-773-6035

*The ten weekdays required for processing of the notification begin when a completed notification form is received. Incomplete or inaccurate notifications will be returned to sender and a new 10 weekday period will begin when a completed notification is received.