APPLICATION FOR ASBESTOS CONTRACTOR LICENSE IDEM – Office of Air Quality Asbestos Program 100 N. Senate Avenue Indianapolis, IN 46204 Phone: (317) 233-3861 www.in.gov/idem State Form 52575 (R / 4-08) Form Approved by State Board of Accounts, 2006 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: This form must be used to apply for an asbestos contractor license pursuant to 326 IAC 18. If accessing this form on-line, you may print the blank form and fill it out by hand; or you may fill it in on-line, then save it to your computer and print a hard copy for submission with original signatures. APPLICATION TYPE Please type or print in ink. Return this form, required addenda, and check or money order made payable to "IDEM Asbestos Trust Fund" by mail to: Type of application (check one): Cashier – Mail Code 50-10C Indiana Dept of Environmental Management 100 North Senate Avenue Indianapolis, Indiana 46204 Initial license Renewal license PART A: GENERAL INFORMATION - TO BE COMPLETED BY ALL APPLICANTS 1. Applicant Name Last First 2. Company name: 3. Company mailing address: Street Middle Initial Company phone #: City ( ) - State ZIP code PART B: PHOTOGRAPHIC IDENTIFICATION - APPLIES TO ALL APPLICANTS ► Pursuant to 326 IAC 18, the applicant shall provide the Department two (2) copies of a clear and recent one and oneLEAVE THESE SPACES BLANK half inch (1-1/2") by one and one-half inch (1-1/2") identifying color photograph of the applicant, or the designated FOR OFFICE USE ONLY representative. Please enclose the photographs with this application. PART C: DESIGNATED REPRESENTATIVE PERSONAL AND TRAINING INFORMATION - TO BE COMPLETED BY ALL APPLICANTS Pursuant to 326 IAC 18, an asbestos contractor applicant must have attended an Indiana-approved training course for asbestos project supervisor or asbestos contractor. A contractor may designate an employee to fulfill these requirements. Personal information for the contractor, or the designated employee, must be given below. Applicant is REQUIRED to attach a copy of the training course certificate, which indicates successful completion of one (1) of the aforementioned asbestos training courses. NOTE: Any transfer of the designated status to another employee must be reported to the Department, in writing, within five (5) working days of the transfer. 4. 5. DESIGNATED REPRESENTATIVE NAME Last Birth Date Month 6. Day / Year / 6820-120000-420000 Sex 7. First Height Male feet Female 8. Middle Initial Weight pounds 9. Eye Color 10. Hair Color 11. Home phone number inches ( ) - Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 52575 (R / 4-08) Application for Asbestos Contractor License PART D: CONTRACTOR MATERIALS TO BE SUBMITTED WITH APPLICATION ► Any contractor seeking an Indiana Asbestos Contractor License or Renewal License must provide the following: 1. A statement that the person has read and understands 326 IAC 18, the Asbestos-Containing Materials in Schools Rule, and 326 IAC 14-10. 2. Provide a copy of all required certificates of training indicating that the contractor, or his designated representative, successfully completed the approved initial and any requisite refresher training courses for asbestos project supervisor or asbestos contractor and received passing scores on all written examinations for such courses. 3. A complete list of prior contracts for the previous twelve (12) months for asbestos projects, including names, addresses, and telephone numbers of persons for whom projects were performed. 4. An up-to-date copy of the contractor's written standard operating procedures, which include current compliance procedures for the following regulatory programs: a) b) c) d) e) f) 326 IAC 14-2 (Emission Standards for Sources of Asbestos), 326 IAC 14-10 (Asbestos Demolition and Renovation Operations), 326 IAC 18 (Asbestos Management Personnel; Licensing), 329 IAC 10-8 (Special Waste), 29 CFR 1926.1101 (Occupational Exposure to Asbestos, Final Rule), 29 CFR 1910.134 (Occupational Safety and Health Standards, Subpart I, Personal Protective Equipment). 5. A description of any asbestos projects that the contractor conducted which were prematurely terminated or not completed, including the circumstances surrounding termination. 6. A list of any contractual penalties related to asbestos activities that the contractor has paid for noncompliance with contract specifications. 7. Copies of any and alI warning letters, Notices and Orders of the Commissioner, Agreed Orders, citations, notices of violation, or findings of violation levied against the contractor by any federal, state, or local governmental agency for violations of regulations or other laws pertaining to asbestos activities, including names and locations of the projects, the dates, and a description of how the allegations were resolved. 8. A description detailing all legal proceedings, lawsuits, warning letters to supervisors from IDEM or claims which have been filed or levied against the contractor or any of the contractor’s past or present employees, while employed by said contractor, for asbestosrelated activities. PART E: FINANCIAL RESPONSIBILITY ► 326 IAC 18 requires that a contractor provide documentation of the contractor's financial responsibility with a current certificate of insurance with at least five hundred thousand dollars ($500,000) of asbestos liability insurance. The company offering insurance coverage must be recognized or licensed by the Indiana Department of Insurance. The Indiana Department of Environmental Management must be listed as a "certificate holder" on the insurance. Attach documentation of this financial responsibility. Any changes in the status of the contractor's financial responsibility must be reported within five (5) working days to the Indiana Department of Environmental Management. PART F: CONTRACTOR LICENSE APPLICATION FEE ► Upon application for an initial or renewal asbestos contractor license, the applicant shall pay a fee in the amount of one hundred fifty dollars ($150). • Make all checks and money orders payable to "IDEM Asbestos Trust Fund". • Pursuant to 326 IAC 18 the nonrefundable application fee is not: - Transferable from one (1) type of asbestos license to another, Transferable from one (1) person to another, Transferable to any other type of license issued by the department, unless requested by the applicant and approved by the department within three (3) days of submittal to the department or prior to application processing by the department, whichever is earlier. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 52575 (R / 4-08) Application for Asbestos Contractor License PART G: CERTIFICATION AND SIGNATURE I hereby certify that there are no misrepresentations in or falsifications of information submitted in this application. I understand that should investigations disclose any falsifications of information submitted in this application, my asbestos contractor license may be revoked. I have read Indiana's asbestos rules 326 IAC 18 and 326 IAC 14-10, and the U.S. Environmental Protection Agency's “Asbestos-Containing Materials in Schools Rule” and I understand the requirements of those rules. I understand that failure to comply with requirements as outlined within federal, state, or local asbestos-related regulations may result in civil and/or criminal penalties. SIGNATURE OF APPLICANT: ________________________________________________ DATE SIGNED: SIGNATURE OF DESIGNATED REPRESENTATIVE:____________________________________________ DATE SIGNED: / / / / BOTH SIGNATURES ARE REQUIRED PART H: NOTES ► IMPORTANT • Allow a minimum of six (6) weeks for processing a complete application package and receipt of your asbestos contractor license. • Make sure you have completed all appropriate sections of this application and have included all required addenda. Sign and date the application and return it to the Cashier address shown on page one (1) of this application. Applications that are incomplete or contain errors in response to any questions on the form will result in a delay in processing and issuance of your asbestos contractor license. All information requested on this application is MANDATORY for the administration and processing of your asbestos contractor license application pursuant to 326 IAC 18. Except for scores on any examination, all other personal data received will be regarded as a public record subject to disclosure in accordance with IC 5-14-3 and 326 IAC 17-1-4. • The person listed In Part C of this form (Designated Representative) must sign both of the wallet-sized signature cards at the bottom of this page. PART I: SIGNATURE CARDS Designated representative must sign both signature cards below. Application will be denied If signature cards are not signed. THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING ASBESTOSRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 18. THIS LICENSE IS ISSUED FOR THE SOLE USE OF THE UNDERSIGNED AND IS NON-TRANSFERABLE. ANY USE OR POSSESSION, EXCEPT AS PRESCRIBED, IS PROHIBITED BY LAW. THIS LICENSE MUST BE IN THE POSSESSION OF THE UNDERSIGNED WHEN PERFORMING ASBESTOSRELATED ACTIVITIES AS PRESCRIBED BY 326 IAC 18. SIGNATURE SIGNATURE Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com