| .1. |
Type of
Notification: Enter "O" if the notification is a
first time or original notification, "R" if the notification is a
revision of a prior notification, or "C" if the activity has been
canceled. |
| .2. |
Facility Information: Enter the
names, addresses, contact persons and telephone numbers of the
following:
- Owner:
Legal owner of the site at which asbestos is being removed or
demolition planned.
- Removal
Contractor: Contractor hired to remove asbestos.
- Other
Operator: Demolition contractor, general contractor, or any other
person who leases, operates, controls or supervises the site.
If
known, the name of the site supervisor should be entered as the contact
person for the notification. If additional parties share responsibility
for this site, demolition activity, renovations or ACM removal, include
complete information (including name, address, contact person and
telephone number) on additional sheets submitted with the form.
|
| .3. |
Type of
Operation: Enter "D" for facility demolition,
"R" for facility renovation, "O" for ordered demolitions, or "E" for
emergency renovations.
|
| .4. |
Is Asbestos
Present? Answer "Yes" or "No" regardless of
the amount or type of asbestos.
|
| .5. |
Facility Description: Provide
detailed information on the areas being renovated or demolished. If
applicable, provide the floor numbers and room numbers where
renovations are to be conducted.
- Site
Location: Provide information needed to locate site in the event that
the address alone is inadequate.
- Building
Size: Provide in square meters or square feet.
- No. of
Floors: Enter the number of floors including basement or ground level
floors.
- Age in
Years: Enter approximate age of the facility.
- Present
Use/Prior Use: Describe the primary use of the facility or enter the
following codes:
- H for Hospital; S for School; P for Public
Building; O for Office; I for
Industrial; U for University
or College; B for Ship; C for
Commercial; or R for Residence.
|
| .6. |
Asbestos
Detection Procedure: Describe methods and procedures
used to determine whether ACM is present at the site, including a
description of the analytical methods employed.
|
| .7. |
Approximate
Amount of Asbestos Including: (1) Regulated
ACM to be removed (including nonfriable ACM to be sanded, ground or
abraded); (2) Category 1 ACM not removed; and (3) Category II ACM not
removed.
For both removals and demolitions, enter the amount of RACM to be
removed by entering a number in the appropriate box and an "X" for the
unit. For demolitions only, enter the amount of Category I and II
nonfriable asbestos not to be removed in the appropriate boxes.
Category I nonfriable material includes packing, gaskets, resilient
floor covering and asphalt roofing materials containing more than one
percent asbestos. Category II nonfriable material includes any
material, excluding Category I products, containing more than one
percent asbestos, that when dry, cannot be crumbled, pulverized or
reduced to powder.
|
| .8. |
Scheduled
Dates of Asbestos Removal (MM/DD/YY): Enter
scheduled dates (month/day/year) for asbestos removal work. Asbestos
removal work includes any activity, including site preparation, which
may break up, dislodge or disturb asbestos material.
|
| .9. |
Scheduled
Dates of Demo/Renovation (MM/DD/YY): Enter
scheduled dates (month/day/year) for beginning and ending the planned
demolition or renovation.
|
| 10. |
Demolition of
Planned Demolition or Renovation Work, and Method(s) to be Used: Include in
this description the demolition and renovation techniques to be used
and a description of the areas and types of facility components which
will be affected by this work.
|
| 11. |
Description
of Engineering Controls and Work Practices to be Used to Control
Emissions of Asbestos at the Demolition and Renovation Site: Describe the
work practices and engineering controls selected to ensure compliance
with the requirements of the regulations, including both asbestos
removal and waste-handling emission control procedures.
|
| 12. |
Waste
Transporter(s): Enter the names, addresses,
contact persons and telephone numbers of the persons or companies
responsible for transporting ACM from the removal site to the waste
disposal site. If the removal contractor or owner is the waste
transporter, state "same as owner" or "same as removal contractor." If
additional parties are responsible, include complete information on an
additional sheet submitted with the form. |
| 13. |
Waste
Disposal Site: Identify the waste disposal site,
including the complete name, location and telephone number of the
facility. If ACM is to be disposed of at more than one site, provide
complete information on an additional sheet submitted with the form.
|
| 14. |
If Demolition
is Ordered by a Government Agency, Please Identify the Agency Below: Provide the
name of the responsible official, title and agency, authority under
which the order was issued, the dates of the order and the dates of the
ordered demolition.
|
| 15. |
Emergency
Renovation Information: Provide the date and time of the
emergency, a description of the event and a description of unsafe
conditions, equipment damage or financial burden resulting from the
event. The information should be detailed enough to evaluate whether a
renovation falls within the emergency exception.
|
| 16. |
Description
of Procedures to be Followed in the Event that Unexpected Asbestos is
Found or Previously Nonfriable Asbestos Material Becomes Crumbled,
Pulverized or Reduced to Power: Provide
adequate information to demonstrate that appropriate actions have been
considered and can be implemented to control asbestos emissions
adequately, including at a minimum, conformance with applicable work
practice standards.
|
| 17. |
Certification
of Presence of Trained Supervisor: One year
after promulgation of the applicable regulation, the notifier must
certify that a person trained in asbestos-removal procedures will
supervise the demolition or renovation. The supervisor is responsible
for the activity on-site. Evidence that the training has been completed
by the supervisor must be available for inspection during normal
business hours.
|
| 18. |
Verification: Please
certify the accuracy and completeness of the information provided by
signing and dating the notification form. |
