APPLICATION CHECKSHEET FOR ASBESTOS CONTRACTOR State Form 52571 (R / 4-08) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: DO NOT RETURN THIS SHEET WITH APPLICATION This checklist is used by IDEM to review your Form 52575 “Application for Asbestos Contractor License” and is provided only to assist you in compiling a complete Standard Operating Procedures manual for submittal with the asbestos contractor license application. IDEM – Office of Air Quality Asbestos Program 100 N. Senate Avenue Indianapolis, IN 46204-2251 Phone: (317) 233-3861 www.in.gov/idem FOR OFFICE USE ONLY Company Name: Applicant Name: Designated Employee Name: Reviewed by: Date reviewed: TYPE OF LICENSE NEW LICENSE RENEWAL LICENSE - Expiration Date: ____/____/____ STATUS OF LICENSE APPROVED DENIED PENDING ADDITIONAL INFORMATION PART A: APPLICATION Have the following items been completed on, or attached to, the license application? YES NO RULE REQUIREMENT – to be completed on or attached to application GENERAL INFORMATION AND ATTACHMENTS 326 IAC 18-1-5(b)(1) General and personal information provided If no, provide the following: __________________________________________________________ 326 IAC 18-1-5(b)(10) Proof of financial responsibility attached Verified: _________________________________________________________________________ 326 IAC 18-1-4(g)(2) Required Training Attended an Indiana-approved asbestos Project Supervisor or Contractor training course and received a passing score on the final written exam during the twelve months prior to application submittal. Contractor may designate an employee to fulfill this training requirement. **New applicants should submit a copy of their initial Supervisor/Contractor training course certificate and each annual Supervisor refresher course certificate received thereafter. There should be no more than 18 months between the starting date of each course. Applicant must have taken and passed the final written exam for the initial course and each refresher course. Verified:_________________________________________________________________________ 326 IAC 18-1-5(b)(3) Training Certificates Copy of training certificate(s) attached *Initial course certificate *Refresher course certificate(s) Standard Operating Procedures (SOP) Manual Copy of contractor's written standard operating procedures for the following regulatory programs is attached: 326 IAC 14-10; 326 IAC 18-1; 329 IAC 10-8-4; 29 CFR 1926.1101; 29 CFR 1910.134. 326 IAC 18-1-5(b)(5) NOTE: Do not attach copies of these rules and regulations. Instead, the SOP manual should include detailed, specific written procedures for contractor’s compliance with Indiana’s asbestos rules. This includes notification, work practice, and licensing requirements. 326 IAC 18-1-5(b)(1) 326 IAC 18-1-5(e) White colored lead signature cards signed and attached Two 1-½ inch by 1-½ inch recent color photographs of applicant attached 326 IAC 18-1-5(b)(1) Application signed 326 IAC 18-1-9(a)(4) Application fee of $150 submitted with application Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Application Checksheet For Lead Contractor 8/01 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 52571 (2-06) PART B: STANDARD OPERATING PROCEDURES MANUAL (SOP) Has contractor included in the SOP their procedures for compliance with the following rules? YES NO RULE REQUIREMENT - to be addressed in the SOP 326 IAC 14-10 APPLICABILITY OF RULE 326 IAC 14-10-1 Demolitions ≥ 260 LF, 160 SF, or 35 CF friable ACM Demolitions < 260 LF, 160 SF, or 35 CF friable ACM Ordered Demolitions Renovations ≥ 260 LF, 160 SF, or 35 CF friable ACM Renovations < 260 LF, 160 SF, or 35 CF friable ACM Emergency Renovations DEFINITIONS 326 IAC 14-10-2 Adequately wetted RACM Asbestos removal project Friable NOTIFICATION REQUIREMENTS/CONTENTS/SCHEDULE/FORM 326 IAC 14-10-3 State of Indiana Indianapolis Air Pollution Control Division ASBESTOS EMISSION CONTROL 326 IAC 14-10-4 Remove all RACM prior to demolition/renovation and exception When removing components as unit or in sections Adequately wet ACM when being stripped before members removed from facility; wetting exemptions When component taken out of facility as unit or in sections For large facility components For all RACM materials that have been removed or stripped When temperature at point of wetting is