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Notification Of Demolition And Renovation Operations Form. This is a Indiana form and can be use in Department Of Enviromental Management Statewide.
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Indiana Department of Environmental Management
GUIDANCE FOR PREPARING ASBESTOS
DEMOLITION/RENOVATION NOTIFICATIONS
**Per Indiana Rule 326 IAC 14-10-3(1), all notifications to the IDEM must be submitted on
State Form Number 44593.
Per 326 IAC 14-10-5, demolition/renovation fees will be assessed quarterly to owners/
Operators submitting notifications during the previous quarter.
I.
Type of Notification -326 IAC 14-10-3(4).
A. If this is the original notice, please check the appropriate space on the notification
form.
B. If this is a revised notice, please check the appropriate space on the notification form.
The revised notice must be postmarked and sent by certified mail, return receipt
requested, at least 5 working days or delivered at least 2 working days before the
start date of asbestos stripping or removal specified in: (1) the notice being
revised and (2) the new revised notice. Facsimiles will be accepted by the IDEM.
C. All revisions must include a copy of the notice being revised.
D. If this is a canceled notice, please check the appropriate space on the notification
form.
E. Courtesy Notification
II.
Facility Information - 326 IAC 14-10-3(3)(B) and (R)
A.
B.
C.
D.
III.
Either the owner or operator must submit the notice.
The owner means the individual(s) who own the property or lease the property.
The operator means the asbestos removal contractor or demolition contractor.
Specify the name, address, telephone number, Indiana license number and license
expiration date, of the:
1. asbestos removal contractor,
2. inspector who conducted the assessment prior to demolition or renovation and
3. project designer required or asbestos projects at schools K-12, or if project
designer is used for non-school projects must be licensed.
Type of Operation - 326-IAC 14-10-3(3)(C), (O) and (S)
A. Refer to the definitions of demolition, renovation, and emergency renovation
Operation in 326-IAC 14-10-2.
B. Ordered demolitions and emergency renovation operations have additional
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Notification requirements. Owner/operator must also complete Section XV or
XVI of notification form.
C. Demolition by intentional burning must comply with an approved Variance from
Opening Burning Regulation 326IAC 4-1.
IV.
Is Asbestos Present? - Required by Federal 40 CFR Part 61, Subpart M
A. If asbestos is present, indicate “yes” in the space provided.
B. If asbestos is not present, indicate “no”.
V.
Procedures, Including Analytical Methods, if appropriate, Used to Detect the Presence
and Amount of Asbestos Material - 326 IAC 14-10-3(3)(E).
Describe how the asbestos was detected and, if samples were analyzed, specify the amount
of friable asbestos visually during a walk-through inspections using a tape measure,
blueprints, or pacing. Analytical methods could include the collection of samples and
sample analyses by a polarized light microscope with dispersion staining.
For samples that test under 10% asbestos content: An owner or operator may (1) elect to
assume material to be greater than 1% asbestos, or, (2) require verification by point
counting in which the point counting result will supercede the visual estimation.
Either choice and result should be stated on the notice when a sample is under 10%
asbestos.
VI.
Approximate Amount of Asbestos to be Removed - 326 IAC 14-10-3(3)(F)
A. Specify the amount of regulated (friable) asbestos-containing material to be
removed as follows:
1. linear feet on pipes,
2. square feet (surface area) on the facility components, and
3. total cubic feet (volume) on or off all facility components. (All reported regulated
amounts must be converted to cubic feet).
B. Estimate the approximate amount of Category I and Category II non-friable
asbestos-containing material in the affected part of the facility that will be removed
before demolition.
C. Estimate the approximate amount of Category I and Category II non-friable
asbestos-containing material in the affected part of the facility that will not be removed
before demolition.
VII.
Scheduled Dates of Asbestos Stripping/Removal - 326 IAC 14-10-3(3)(H)
This means the actual start and end dates of the asbestos stripping or removal.
VIII.
Scheduled Dates of Asbestos Stripping/Removal - 326 IAC 14-10-3(3)(H)
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This means the starting and ending dates of the total demolition or renovation operation.
For example: A renovation project may be scheduled from February 1 through March 15,
1995, however, the actual asbestos removal will occur from February 15, through 20,
1995. Demolition must start on date given in most recent notification.
.
IX
Facility Description - 326 IAC 14-10-3(3)(D) and (G)
Include the building name, floor and number of the room(s) where the asbestos stripping
or removal will take place. Provide enough detail that an unfamiliar inspector can find the
asbestos project without asking anyone.
X.
Description of planned Demolition or Renovation Work, Methods/Techniques to be Used,
and Affected Facility Components - 326 IAC 14-10-3(3)(K)
Briefly describe the methods to be used to conduct the demolition or renovation. For
renovations, these methods may include gross removal, glove bag removal, hand stripping
or scraping. For demolitions, methods may include a wrecking Ball, bulldozer, dynamite,
or unbolting panels or sections and carefully lowering to the ground. Affected facility
components may include pipe wrap, floor tile, sprayed-on insulation, transite, etc.
XI.
Description of Work Practices and Engineering Controls To Be Used To Prevent
Emissions of Asbestos At the Site, Including Asbestos Stripping, Removal, and Waste
Handling Procedures and the Procedures to Prevent Non-Friable Asbestos Material from
Becoming Friable in the Course of the Project 326 IAC 14-10-3(3)(L)
A. Examples of work practices and engineering controls to prevent asbestos emissions at
the site would include: the use of water or wetting agents, containments, and
negative air units during removal; placing into leak-tight containers or wrapping with
six (6) mil thick polyethylene plastic sheeting which is properly labeled prior to
disposal, etc.
B. Examples of removal and waste handling procedures to prevent non-friable material
from becoming friable would include: removing by sections or units taking care not to
crumble, pulverize, or reduce to power, using water to prevent any emissions, placing
into leak-tight containers or wrapping with six (6) mil thick plastic which is properly
labeled prior to disposal (including name or waste generator and location at which the
waste was generated), etc.
XII.** Description of Procedures to be Followed in the Event that Unexpected Asbestos is Found
or Previously Non-Friable Asbestos Material Becomes Crumbled, Pulverized or Reduced
to Powder - 326 IAC 18-3 and 326 IAC 14-10-3(3)(M).
A. If the amount of unexpected asbestos or previously non-friable asbestos material is > 3
LnFt on pipes, 3 SqFt on other facility components, or a total of 0.75 CuFt on or off
all facility components, then an accredited contractor (unless in-house accredited
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personnel) with accredited personnel must implement the asbestos removal project in
accordance with the requirements of 326 IAC 14-10.
B. Pursuant to 326 IAC 14-10, a revised demolition/renovation notification must be
submitted to the IDEM, which reflects the change in the amount of affected asbestoscontaining material. The revised notice must also reflect the new asbestos removal
start date, if applicable.
** Required by 40 CFR Part 61, Subpart M
XIII.
Waste Transporter - 326 IAC 14-10-3(3)(T)
Provide the name, address and telephone number of only the asbestos waste transporter.
This should include the waste transporter’s name, street address, city, state, zip code,
contact person, and telephone number.
XIV. Waste Disposal site - 326 IAC 14-10-3(3)(N)
Provide the name and location of the sanitary landfill where the asbestos-containing waste
material will be deposited. This should include the name, street address, city, state, zip
code, waste disposal site contact person, and telephone number.
XV.
If Demolition Ordered by a Governmental Agency, Identify the Agency and Attach a Copy
of the Order - 326 IAC 14-10-3(3)(O)
A. Provide the name, title and authority of the of the state or local governmental
representative who has ordered the demolition .
B. The authority is the applicable state or local regulation under which the demolition
order has been issued.
C. Attach a copy of the demolition order to the notice.
XVI. Emergency Renovations - 326 IAC 14-10-3(3)(S)
A. Specify
1. the date and hour that the emergency occurred,
2. a description of the sudden unexpected event, and
3. an explanation of how the event has caused emergency conditions
B. An “emergency renovation operation” is a renovation operation that was not planned
but results from a sudden, unexpected event. This term includes operations
necessitated by non-routine failures of equipment.
XVII. Certification Statement and Signature by Owner/Operator - 326 IAC 14-10-3(3)(O) and
(P)
Self-explanatory.
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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTIFICATION OF DEMOLITION AND RENOVATION OPERATIONS
State From 44593 (R2 / 8-99)
I.
TYPE OF NOTIFICATION (check one):
II.
FACILITY INFORMATION (identify owner, removal contractor, demolition contractor, inspector, and project designer)
Original
Revised *
Canceled
* Must include copy of notification which is being revised
Courtesy
Owner:
Address:
City:
State:
Contact:
Telephone #:
Removal
Contractor:
Demolition
Contractor:
Address:
Zip:
Address:
City:
State:
Zip:
Contact:
Phone:
IN License #:
City:
State:
Contact:
Zip:
Phone:
Expiration:
(Required for asbestos projects at schools K – 12)
Inspector:
Project Designer:
Address:
Address:
City:
State:
IN License #:
Zip:
City:
Expiration:
IN License #:
Phone:
III.
State:
Zip:
Expiration:
Phone:
TYPE OF OPERATION (check one)
Renovation:
Demolition:
Intentional Burning:
Emergency Renovation:
Ordered Demolition:
IV.
IS ASBESTOS PRESENT? (check one)
V.
PROCEDURES, INCLUDING ANALYTICAL METHODS, IF APPROPRIATE. USED TO DETECT THE PRESENCE AND AMOUNT OF ASBESTOS MATERIAL
VI.
APPROXIMATE AMOUNT OF ASBESTOS (Including Regulated ACM, Category I non-friable Category II non-friable ACM)
YES:
NO:
Non-friable Asbestos Material
To be removed
Regulated
ACM to be removed
Category I
Non-friable Asbestos Material
Not to be removed before demolition
Category II
Category I
Category II
Pipes (LnFt)
Surface Area (SqFt)
Total Volume (CuFt)
on/off Components
VII.
SCHEDULED DATES OF ASBESTOS STRIPPING/REMOVAL:
VIII.
IX.
SCHEDULED DATES OF RENOVATION:
Start:
Start:
End:
End:
DEMOLITION:
Start:
End:
FACILITY DESCRIPTION (Including building name, floor, and room number)
Building Name:
Street Address:
City:
State:
County:
Location of removal within building:
Building Size (SqFt):
# of Floors:
Present Use:
Age:
Prior use:
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X.
DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK, METHODS/TECHNIQUES TO BE USED, AFFECTED FACILITY COMPONENTS AND
TYPE OF MATERIALS REMOVED
XI.
DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS OF ASBESTOS AT THE SITE;
INCLUDING ASBESTOS STRIPPING, REMOVAL AND WASTE HANDLING PROCEDURES TO PREVENT NON-FRIABLE ASBESTOS MATERIAL FROM
BECOMING FRIABLE IN THE COURSE OF THE PROJECT:
XII.
DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND OR PREVIOUSLY NON-FRIABLE ASBESTOS
MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED POWDER:
XIII.
WASTE TRANSPORTER
XIV.
WASTE DISPOSAL SITE
Name:
Name:
Address:
Address:
City:
State:
Contact:
XV.
Zip:
City:
Phone:
Contact:
Zip:
Phone:
IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, IDENTIFY THE AGENCY BELOW AND ATTACH A COPY OF THE ORDER TO THIS FORM. IF THE
FACILITY IS NOT INSPECTED PRIOR TO DEMOLITION, THE DEBRIS MUST BE KEPT ADEQUATELY WET. THE DEBRIS MUST THEN BE INSPECTED AFTER
DEMOLITION OR ASSUME ALL DEBRIS TO BE CONTAMINATED WITH RACM AND DISPOSED OF APPROPRIATELY TO COMPLY WITH 326 IAC 14-10-1(b).
Name:
Title:
Date ordered to begin:
Authority:
XVI.
State:
Date of Order:
FOR EMERGENCY RENOVATIONS:
Date and time of emergency:
Description of sudden, unexpected event:
Explanation of how the event caused unsafe conditions or would cause equipment damage:
XVII.
I HEREBY CERTIFY THAT THE INFORMATION IN THIS NOTIFICATION IS CORRECT AND THAT I WILL ONLY USE INDIANA LICENSED WORKERS AND PROJECT
SUPERVISORS, TO IMPLEMENT THIS ASBESTOS PROJECT, WHICH HAVE BEEN TRAINED IN 326IAC 14-10; 40 CFR PART 61, SUBPART M; AND, IF APPLICABLE,
INDIANAPOLIS AIR POLLUTION CONTROL BOARD REGULATION 14. THE TRAINED INDIVIDUAL(S) ALONG WITH EVIDENCE THAT THE REQUIRED TRAINING
WAS ACCOMPLISHED SHALL BE AVAILABLE AT THE JOB SITE DURING ACTUAL WORKING HOURS.
Owner/operator (signature)
date
Owner/operator (printed)
affiliation
**************************************************************
POSTMARK:
RECEIVED:
OFFICE USE ONLY
***********************************************************************
REVIEWED BY:
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