TX Demo Reno Notification Form.pdf

DEMOLITION / RENOVATION

NOTIFICATION FORM

NOTE: CIRCLE ITEMS THAT ARE AMENDED

NOTIFICATION#

1) Abatement Contractor: DSHS License Number:

Address : City: State: Zip:

Office Phone Number: ( ) Job Site Phone Number:( ) Site Supervisor: DSHS License Number:

Site Supervisor: DSHS License Number:

Trained On-Site NESHAP Individual: Certification Date:

Demolition Contractor: Office Phone Number( ) Address: City: State: Zip:

2) Project Consultant or Operator: DSHS License Number:

Mailing Address:

City: State: Zip: Office Phone Number: ( )

3) Facility Owner:

Attention:

Mailing Address:

City: State: Zip: Owner Phone Number( ) **Note: The invoice for the notification fee will be sent to the owner of the building at the address listed in this section after the project is completed.

4) Description or Facility Name:

Physical Address: County: City: Zip:

Facility Phone Number( ) Facility Contact Person:

Description of Area/Room Number:

Prior Use: Future Use:

Age of Building/Facility: Size: Number of Floors: School (K - 12): YES NO

5) Type of Work (CHECK ONLY ONE): Demolition Renovation (Abatement) Annual Consolidated Work will be during: Day Evening Night Phased Project Description of work schedule:

6) Type of Building (CHECK ONLY ONE): Public Building Federal Facility Industrial Site NESHAP-Only Facility Is Building/Facility Occupied? YES NO

7) Notification Type (CHECK ONLY ONE):

Original (10 Working Days) Amendment Cancellation Emergency Ordered (see item 15) If this is an amendment, which amendment number is this? (Enclose copy of original and/or last amendment) If an emergency, who did you talk with at DSHS? Emergency#:

Date and Hour of Emergency (HH/MM/DD/YY): / / / Description of the sudden, unexpected event and explanation of how the event caused unsafe conditions or would cause equipment damage (computers, machinery, etc

8) Description of procedures to be followed in the event that unexpected asbestos is found or previously non-friable asbestos material becomes crumbled, pulverized, or reduced to powder:

9) Was an Asbestos survey performed? YES NO Date: / / DSHS Inspector License No: _____________ Analytical Method: PLM TEM Assumed DSHS Laboratory License No: ______________ (For TAHPA (public building) projects: an assumption must be made by a DSHS Licensed Inspector)

10) Description of planned demolition or renovation work, type of material, and method(s) to be used:

11) Description of work practices and engineering controls to be used to prevent emissions of asbestos at the demolition/renovation:

F O R

F F I C E

U S

N L Y

T A H P

S H

P

T

H

L

V I O L A T I O

Y

S

12) ALL applicable items in the following table must be completed: IF NO ASBESTOS PRESENT CHECK HERE

Approximate amount of Asbestos

Check unit of measurement

Asbestos-Containing Building Material Type

Pipes Surface Area

Ln Ft

Ln M

SQ

SQ

Cu

Cu

RACM to be removed

RACM NOT removed

Interior Category I non-friable removed

Exterior Category l non-friable removed

Category I non-friable NOT removed

Interior Category ll non-friable removed

Exterior Category II non-friable removed

Category II non-friable NOT removed

RACM Off-Facility Component

13) Waste Transporter Name: DSHS License Number:

Address: City: State: Zip:

Contact Person: Phone Number: ( )

14) Waste Disposal Site Name:

Address: City: State: Zip:

Telephone: ( ) TCEQ Permit Number:

15) For structurally unsound facilities, attach a copy of demolition order and identify Governmental Official below:

Name: Registration No:

Title:

Date of order (MM/DD/YY) / / Date order to begin (MM/DD/YY) / /

16) Scheduled Dates of Asbestos Abatement (MM/DD/YY) Start: / / Complete: / /

17) Scheduled Dates Demolition/Renovation (MM/DD/YY) Start: / / Complete: / / ** Note: If the start date on this notification can not be met, the DSHS Regional or Local Program office Must be contacted by phone prior to the start date. Failure to do so is a violation in accordance to TAHPA, Section 295.61.

I hereby certify that all information I have provided is correct, complete, and true to the best of my knowledge. I acknowledge that I am responsible for all aspects of the notification form, including, but not limiting, content and submission dates. The maximum penalty is $10,000 per day per violation.

(Signature of Building Owner/ Operator (Printed Name) (Date) (Telephone) or Delegated Consultant/Contractor)

(Fax Number)

MAIL TO: ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP

DEPARTMENT OF STATE HEALTH SERVICES

*Faxes are not accepted* PO BOX 143538 *Faxes are not accepted*

AUSTIN, TX 78714-3538

PH: 512-834-6612, 1-888-778-9440

Form APB#5, dated 05/01/05. For assistance in completing form, call 1-888-778-9440