2700-FM-BAQ0021 Rev. 12/2016 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF ENVIRONMENTAL PROTECTION BUREAU OF AIR QUALITY ASBESTOS ABATEMENT AND DEMOLITION/RENOVATION NOTIFICATION FORM For Official Use Only Postmark Date: Project ID#: Permit #: Other #: Inspector: NOTICE: This is not a valid asbestos abatement notification for the purposes of the Asbestos Occupations Accreditation and Certification Act unless individuals and contractors have met the certification requirements as set forth in the Asbestos Occupations Accreditation and Certification Act, Act of 1990, P.L. 805, No. 194 (63 P.S. Sections 2101-2112). Date Received 1 Date Received 2 REFER TO THE ATTACHED INSTRUCTIONS FOR INFORMATION AND REQUIREMENTS. 1. TYPE OF NOTIFICATION (check one): Revision (highlight here, and changes) Postponement Initial Phase of Annual Notification Cancellation Annual Notification Date of Initial Notification or, if previously revised, date of last revision: 2. PROJECT LOCATION (check one): Allegheny County City of Philadelphia Other Location in PA (specify county): Municipality (specify): 3. FOR ALLEGHENY COUNTY AND CITY OF PHILADELPHIA PROJECTS ONLY: A. Does this project require a permit? Yes No (If Yes is checked, a permit application must be submitted along with this notification and approved prior to the start of the project.) B. For City of Philadelphia projects requiring a permit: Asbestos project inspector: Certification #: Company name: Address: City: State: Zip: Phone: WILL ALTERNATIVE METHODS TO ANY OF THE APPLICABLE REGULATIONS BE USED? Yes No (If Yes is checked, approval must be obtained prior to the start of the project. Please contact the appropriate DEP regional office or local government agency (see reverse of Instruction Sheet for contact list). TYPE OF OPERATION (check all that apply): Demolition Ordered Demolition FACILITY DESCRIPTION: Facility Name: Street/Rural Address: City: Present use: Will the facility be occupied during the abatement activity? Facility size in square feet: Yes # of floors: Prior use: No Age in years: State: PA Zip Code: Abatement prior to Demolition Renovation Emergency Renovation Job No.: (see instructions) 4. 5. 6. 7. ABATEMENT CONTRACTOR: Company name: Allegheny County or City of Philadelphia License # (if applicable): Street/Rural/POB Address: City: Contact: State: Zip: Telephone No. (between 8:00 & 4:30): -1- American LegalNet, Inc. www.FormsWorkFlow.com 2700-FM-BAQ0021 Rev. 12/2016 8. DEMOLITION CONTRACTOR: Company name: Street/Rural/POB Address: City: Contact: State: Zip: Telephone No. (between 8:00 & 4:30): 9. FACILITY OWNER: Owner name: Street/Rural/POB Address: City: Contact: State: Zip: Telephone No. (between 8:00 & 4:30): 10. FACILITY INSPECTION (required for renovation and demolition projects): Building inspector: Date of inspection: Certification #: Is any material assumed to be asbestos? Yes No Procedure, including analytical method, if appropriate, used to detect the presence of asbestos material: Building is ID and in danger of collapse. An asbestos investigator will be on site during demolition. (Philadelphia only) 11. 12. IS ANY TYPE OF ASBESTOS PRESENT? Yes No If Yes, please list in #12. TYPE OF ACM, DESCRIPTION & LOCATION OF MATERIAL, APPROXIMATE AMOUNT OF ACM, TYPE OF ABATEMENT AND FINAL AIR CLEARANCE METHOD. PROVIDE INFORMATION IN THE SPACES BELOW, THEN CONTINUE ON ANOTHER SHEET, IF NECESSARY, USING THE SAME FORMAT. Location of material (room/floor/area) Amount of ACM Code ** Code *** Code **** Code * Description of material Code * Type of ACM Code ** Units Code *** Type of abatement Code **** Final Clearance FRI - Friable ACM LF - Linear ft. REM - Removal PCM - Phase contrast microscopy NF1 - Cat I nonfriable ACM SF - Square ft. CAP - Encapsulation TEM - Transmission electron microscopy NF2 - Cat II nonfriable ACM CF - Cubic ft. CLO - Enclosure (Note: Allegheny County NON - None treats all ACM as friable) 13. Is this project regulated by NESHAP? Yes No A project that includes the demolition of any defined "facility" is regulated by NESHAP. A renovation project is also regulated by NESHAP when the amounts of friable ACM, or ACM that may be rendered friable, are as follows: 260 LF or 160 SF or 35 CF. -2- American LegalNet, Inc. www.FormsWorkFlow.com 2700-FM-BAQ0021 Rev. 12/2016 14. OPERATION SCHEDULE(S) (as applicable): A. Asbestos abatement: Daily hours of operation: Days of week (check): Demolition: Daily hours of operation: Days of week (check): Renovation: Daily hours of operation: Days of week (check): Start Date: am Mo Tu Start Date: am Mo Tu Start Date: am Mo Tu We Th pm We Th pm We Th pm Completion Date: to Fr Sa Completion Date: to Fr Sa Completion Date: to Fr Sa am Su pm B. am Su pm C. am Su pm COMMENTS: 15. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK: 16. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO REMOVE ACM AND TO PREVENT EMISSIONS OF ASBESTOS AT THE DEMOLITION AND RENOVATION SITE: 17. WASTE TRANSPORTER(S): A. Transporter #1 name: Street/Rural Address: City: Contact: B. Transporter #2 name: Street/Rural Address: City: Contact: State: Telephone: Zip: State: Telephone: Zip: -3- American LegalNet, Inc. www.FormsWorkFlow.com 2700-FM-BAQ0021 Rev. 12/2016 18. WASTE DISPOSAL SITE(S) (any asbestos containing material): A. Landfill name: Street/Rural Address: City: Contact: B. Landfill name: Street/Rural Address: City: Contact: State: State: DEP permit #: Zip: Telephone: DEP permit #: Zip: Telephone: 19. AIR MONITORING FIRM(S): A. Company name/individual: Street/Rural Address: City: Contact: B. Final clearance firm: (if different than 19A) Street/Rural Address: City: Contact: Final clearance firm was hired by (check one): Other: Explain: Contractor State: Telephone: Owner Zip: State: Telephone: Zip: 20. AIR SAMPLE FIRM(S) (City of Philadelphia projects only): A. PCM company name/individual: Street/Rural Address: City: Contact: B. TEM company name: Street/Rural Address: City: Contact: State: State: Certification #: Zip: Telephone: Certification #: Zip: Telephone: 21. FOR EMERGENCY RENOVATIONS: Date of emergency (mm/dd/yy): Description of the sudden, unexpected event: Hour of emergency: am pm Explanation of how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden as a consequence of complying with the 10 working day notification requirement: -4- American LegalNet, Inc. www.FormsWorkFlow.com 2700-FM-BAQ0021 Rev. 12/2016 22. FOR ORDERED DEMOLI