SOW_SubAttachment_3-2_-_UFGS_02_41_00_Atch_-_TX-AsbestosDemoNotifcationForm.pdf

FORM APB #5, REV 5/07

ASBESTOS/DEMOLITION NOTIFICATION FORM

SECTION 1: TYPE OF NOTIFICATION

TYPE OF NOTIFICATION: (Select one and fill in the requested information)

ORIGINAL AMENDMENT No. CANCELLATION

EMERGENCY

Was emergency request made to the Regional Office or Environmental Health Notifications Group (EHNG) by phone?

Yes No

If yes, the DSHS reference #: and name of the Regional or EHNG representative with whom you spoke?

Date: / / Time: a.m. p.m.

Describe the reason for Emergency:

ORDERED: (For structurally unsound facilities, attach copy of demolition order and identify Governmental Official)

Name: Registration No.

Title:

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

(x)

Below if

Amended

TYPE OF WORK

Asbestos Abatement Demolition Annual Consolidated O&M Abatement/Demolition

Is this a phased project? Yes No

FACILITY INFORMATION

1. Facility Location

……. Description or Facility Name:

……. Physical Address:

……. County: City: Zip:

……. Facility Contact: Phone #: ( ) -

2. Type of Facility (Select one)

Public Federal Industrial/Manufacturing NESHAP-Only Public School K-12

3. Facility Details

…… Description of Area/Room Number:

…… Age of Building: Size: Number of Floors:

…… Is this building occupied? Yes No

…… Prior Use:

…… Future Use:

…… Date of Asbestos Survey/NESHAP Inspection: / /

…… DSHS Inspector License #:

…… Analytical Method: PLM TEM Assumed Asbestos No Suspect Material

…… DSHS Laboratory License #:

WORK SCHEDULE/ASBESTOS AMOUNTS (Note: if the start date(s) entered below cannot be met, the DSHS Regional or Local

Program office must be notified prior to the scheduled start date. Failure to do so is a violation of TAHPA Section 295.61.)

1. Asbestos Abatement Work Schedule:

…… Start date: / / and End date: / /

…… Work days: Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

…… Working hours: a.m. p.m. to a.m. p.m.

2. Demolition Work Schedule:

…… Start date: / / and End date: / /

…… Work days: Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

…… Working hours: a.m. p.m. to a.m. p.m.

DO NOT WRITE IN THIS BOX- FOR DEPARTMENT USE ONLY

Date received:___/___/___ Postmark date:___/___/___ Walk-in date:___/___/___

For Office Use Only:

Notification #:________________________

AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the left-hand side of this form to indicate amended information.

Below if

Amended

C. ASBESTOS AMOUNTS

…… Is Asbestos Present? Yes No (Complete the table below if asbestos is present)

Asbestos-Containing Building Material Type Approximate amount of

Asbestos

*Only mark the boxes below on this chart if they are being amended Pipes Ln

Ft

Ln

M

Surface Area SQ

Ft

SQ

M

Cu

Ft

RACM to be removed

RACM left in place during demolition

Interior Category I non-friable removed

Exterior Category I non-friable removed

Category I non-friable left in place during demolition

Interior Category II non-friable removed

Exterior Category II non-friable removed

Category II non-friable left in place during demolition

RACM Off-Facility Component

DESCRIPTION OF WORK PRACTICES AND PROCEDURES

…… 1. 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:

…… 2. Description of planned demolition or abatement work, type of material, and method(s) to be used:

……. 3. Description of work practices and engineering controls to be used to prevent emissions of asbestos at the demolition site:

PROJECT INFORMATION

…… A. FACILITY OWNER

Facility Owner Name:

Phone #: ( ) -

Attention:

Mailing Address:

City: State: Zip:

…… B. ASBESTOS ABATEMENT CONTRACTOR #1

DSHS Asbestos Contractor License #:

Contractor Name:

Address:

Office Phone #: ( ) - Job-Site Phone #: ( ) -

…… C. ASBESTOS ABATEMENT CONTRACTOR #2 (Only if there is more than one Contractor)

DSHS Asbestos Contractor License #:

Contractor Name:

Address:

Office Phone #: ( ) - Job-Site Phone #: ( ) -

D. ASBESTOS SUPERVISOR

…… DSHS Supervisor License #: Site Supervisor:

…… DSHS Supervisor License #: Site Supervisor:

Below if

Amended E. NESHAP TRAINED INDIVIDUAL …… NESHAP Trained Individual:

Certification Date: / /

……F. DEMOLITION CONTRACTOR

Demolition Contractor:

Address:

City: State: Zip: Phone #: ( ) -

……G. PROJECT CONSULTANT OR OPERATOR

DSHS License No.:

Project Consultant or Operator:

Address:

City: State: Zip: Phone #: ( ) -

…… H. Waste Transporter

DSHS Waste Transporter License #:

Waste Transporter:

Address:

Contact Person: Phone #: ( ) -

……I. Waste Disposal Site

TCEQ Permit #:

Waste Disposal Site:

Address:

Phone #: ( ) -

CERTIFICATION STATEMENT

I hereby declare that I have examined this notification and, to the best of my knowledge and belief, all information provided is complete, true, and correct. I affirm that I am the owner, operator, or delegated agent and that I am responsible for the fee associated with this notification. I also understand that the owner, operator, or delegated agent is responsible for notification to the department.

Date: / /

(Signature of Owner, Operator or Delegated Agent)

(Printed Name & Title)

E-mail Address: Phone #: ( ) -

IMPORTANT INFORMATION

NOTIFICATION TIMELINESS REQUIREMENT:

Your Asbestos/Demolition Notification form must be postmarked no less than ten working days (not calendar days) prior to the start of any asbestos abatement or demolition.

FILING FEE: An invoice will be mailed to the facility owner upon completion of the project.

CALL FOR ASSISTANCE: (512) 834-6747 or (888) 778-9440 (toll free in Texas)

MAIL FORM TO: ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

PO BOX 143538

AUSTIN, TX 78714-3538