GSA_ACM_Notification_Form.pdf

Notification of Asbestos Demolition and/or Renovation

General Services Administration Region 5

Chicago, IL 60604

1. TYPE OF NOTIFICATION: (check one) Original Revision Cancellation

2. FACILITY INFORMATION (provide names and phone numbers):

GSA Project Manager: _____________________________________________ GSA Property Manager: ____________________________________________ GSA Regional Environmental Engineer: ________________________________ GSA’s A/E Project Manager: _________________________________________ GSA’s Government Environmental Consultant: __________________________ GSA Emergency Contact: ___________________________________________

3. REMOVAL CONTRACTOR INFORMATION:

Company name and Address: ________________________________________ City, State, and zip code: ___________________________________________ Name of contact and phone number: __________________________________

4. FACILITY DESCRIPTION:

Building Name and GSA Building Number: ______________________________ Street Address: ___________________________________________________ City, State, and zip code: ___________________________________________ Building size: __________ Number of Floors: _______ Age of Building: _______ Current Use of Building: _________________ Tenants that may be impacted: _______________________________________

5. DESCRIBE THE PROCEDURES THAT WERE USED TO VERIFY THE PRESENCE

OF ASBESTOS CONTAINING MATERIAL: ___________________

6. WASTE INFORMATION, Provide Company, contact name, and phone no:

Waste Transporter: ________________________________________________ Waste Disposal Site: _______________________________________________ Estimated Quantity of Asbestos Containing Waste: _______________________

7. LIST THE APPROXIMATE QUANTITIES OF ASBESTOS TO BE REMOVED:

Friable ACM:

Component Quantity

Category I Non-Friable ACM (packings, gaskets, resilient floor coverings and adhesive mastics, and asphalt roofing products):

Category II, Non-Friable ACM (all other Non-Friable ACM)

8. SCHEDULED REMOVAL DATES:

Start Date_________________ Completion Date: _____________ Scheduled Working Hours: ________________________________

9. PROVIDE A DESCRIPTION OF THE PLANNED ASBESTOS METHODS TO BE

USED:

10. PROVIDE A DESCRIPTION OF THE ENGINEERING CONTROLS THAT WILL BE

USED TO PREVENT THE EMMISSIONS OF ASBESTOS DURING THE PROJECT:

11. CONTRACTOR’S CERTIFICATION:

“I certify that a trained individual, licensed as a Contractor Supervisor, in the State where the work is being performed, and who satisfies the requirements of a Competent Person will be on site at all times when any asbestos related work is occurring.

Name, title, and Signature of Contractor Date