J-0200000-05 EPA Demolition-Renovation-Notification-Form_fillable.pdf

NOTIFICATION OF DEMOLITION AND RENOVATION

Operator Project # Postmark Date Received Notification #

I. Type of Notification (O=Original R=Revised C=Canceled)

II. FACILITY INFORMATION (Identify owner, removal contractor, and other operator)

OWNER NAME:

Address:

City: State: Zip:

Contact: Tel:

REMOVAL CONTRACTOR:

Address:

City: State: Zip:

Contact: Tel:

OTHER OPERATOR:

Address:

City: State: Zip:

Contact: Tel:

III. TYPE OF OPERATION (D=Demo O= Ordered Demo R=Renovation E=Emer. Renovation)

IV. IS ASBESTOS PRESENT? (Yes/No)

V. FACILITY DESCRIPTION (Include building name, number and floor or room number)

Bldg. Name:

Address:

City: State: County:

Site Location:

Building Size: # of Floors: Age in Years:

Present Use: Prior Use:

VI. PROCEDURE, INCLUDING ANALYTICAL METHOD, IF APPROPRIATE, USED TO DETECT THE PRESENCE OF ASBESTOS MATERIAL:

VII. APPROXIMATE AMOUNT OF ASBESTOS

INCLUDING:

Nonfriable Asbestos

Material Not To Be Removed

Indicate Unit of Measurement Below

1. Regulated ACM to be Removed

2. Category I ACM Not Removed

3. Category II ACM Not Removed

RACM

To Be

Removed Category I Category II UNIT

Pipes LnFt: Ln M:

Surface Area SqFt: Sq M:

Vol RACM Off Facility Component CuFt: Cu M:

VIII. SCHEDULED DATES ASBESTOS REMOVAL (MM/DD/YY) Start: Complete:

IX. SCHEDULED DATES DEMO/RENOVATION (MM/DD/YY) Start: Complete:

X. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK, AND METHOD(S) TO BE USED:

XI. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS OF ASBESTOS AT THE

DEMOLITION OR RENOVATION SITE:

XII. WASTE TRANSPORTER #1

Name:

Address:

City: State: Zip:

Contact Person: Tel:

WASTE TRANSPORTER #2

Name:

Address:

City: State: Zip:

Contact Person: Tel:

XIII. WASTE DISPOSAL SITE

Name:

Address:

City: State: Zip:

Tel:

XIV. IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, PLEASE IDENTIFY THE AGENCY BELOW:

Name: Title:

Authority:

Date of Order (MM/DD/YY): Date Ordered to Begin (MM/DD/YY):

XV. FOR EMERGENCY RENOVATIONS:

Date and Hour of Emergency (MM/DD/YY):

Description of the sudden unexpected event:

Explanation of how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden:

XVI. DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND OR PREVIOUSLY

NONFRIABLE ASTESTOS MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO POWDER:

XVII. I CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF THIS REGULATION (40 CFR PART 61, SUBPART M) WILL BE ON- SITE DURING THE DEMOLITION OR RENOVATION, AND EVIDENCE THAT THE REQUIRED TRAINING HAS BEEN ACCOMPLISHED BY THIS

PERSON WILL BE AVAILABLE FOR INSPECTION DURING NORMAL BUSINESS HOURS.

(Signature of Owner/Operator)

(Date)

XVIII. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT:

(Signature of Owner/Operator)

(Date)