Form Il532-1296 - Demolition/renovation/asbestos Project Notification Form
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2STATE OF ILLINOIS DEMOLITION/RENOVATION/ASBESTOS PROJECT NOTIFICATION FORM
Environmental Protection Agency (IEPA): Projects of at least 160 sq./ft or
Cook County (excluding the City of Chicago): All projects in Cook County must
260 linear ft., or 1 cubic meter and all demolition projects shall be submitted
notify Cook County Environmental Control & IEPA if applicable. This form and
to IEPA.This form shall be submitted for all original notifications and
appropriate fee shall be submitted for all original notifications to Cook County
revisions to IEPA ($150) Attach Illinois E-Pay receipt if paid electronically.
($200). A Cook County Revision Form must be used to cancel an asbestos permit.
Illinois Department of Public Health (IDPH): Abatement projects greater
City of Chicago: All projects in the City of Chicago, except residential
than 3 sq./ft and or 3 linear ft. up to 160 sq.ft or 260 linear feet and all
renovations in buildings with fewer than two dwelling units, must notify the
school projects shall be submitted to IDPH. This form shall be submitted for
City & IEPA if applicable. This form and appropriate fee shall be submitted
all original notifications and revisions to IDPH (no fee).
for all notifications to the City of Chicago (see bottom pg 2 for fee amount).
Copies of this form may be found at:
Date:
Illinois E-Pay Authorization Code (IEPA Only):
TYPE OF NOTIFICATION: o
o
o
o
o
o
o
original
demolition
renovation
cancellation
revision
ordered demolition
annual
Check Type of Project Below:
(Check all that apply.)
o
o
o
Friable School Project
Non-Friable School Floor Tile Project
Commercial Public Building (Friable & Non-Friable)
Revised by:
o
o
o
Contractor
Owner
Project Designer
#of times revised:
List Section #’s being revised:
1. FACILITY INFORMATION:
Facility name:
School Bldg ID:
Location of Asbestos Containing Material (ACM) in Structure:
Bldg Size:
Sq.Ft.:
#Flrs:
Age:
Present Use:
Prior Use:
Future Use (demo)
Address:
City:
County:
Zip:
Contact:
Phone:
2. FACILITY OWNER OR SCHOOL DISTRICT:
(Tip: Complete for all projects Commercial/Public or Schools)
Facility Owner Name:
Address:
City:
State:
Zip:
Contact:
Phone:
Copies of abatement permission and written verification certification to all building occupants and users from the building owner or school board shall be
submitted for IDPH public and private school facilities as required by Section 855.350 of the IDPH Asbestos Code.
3. ASBESTOS CONTRACTOR NAME:
ID#:
Address:
City:
State:
Zip:
Contact:
Phone:
4. DEMOLITION CONTRACTOR NAME:
Address:
City:
State:
Zip:
Contact:
Phone:
o
o
5. ABATEMENT INFORMATION:
Is Asbestos Present?
Yes
No
Description of Planned Demolition or Renovation Work and Methods to be Employed Including Demolition or Renovation Techniques:
Description of Work Practice(s) and Engineering Controls used to Prevent Emissions at the Demolition or Renovation Site:
6. Quantities:
Regulated Asbestos
Non-friable asbestos not to
Non-friable asbestos
Containing Material to
be removed (demolition)
to be removed
TOTAL ASBESTOS
be removed (RACM)
CAT I
CAT II
CAT I
CAT II
TO BE REMOVED
Pipes (Ln. Ft.):
Surface Area (Sq. Ft.):
Volume (Cu. Ft.):
Tip: CAT I non-friable ACM are asbestos-containing resilient floor coverings (vinyl asbestos tile (VAT), asphalt roofing products, packing and gaskets.
All other non-friable ACM are considered CAT II non-friable ACM. (RACM) is (a) friable asbestos material, (b) Category I non-friable ACM that has
become friable, (c) Category I non-friable ACM that will be or has been subjected to sanding, grinding, cutting or abrading, or (d) Category II non-friable
ACM that has a high probability of becoming or has become crumbled, pulverized or reduced to powder by the forces expected to act on the material in
the course of demolition or renovation operations.
o
o
o
o
7. ABATEMENT START DATE:
Finish Date:
Work hours:
AM
PM
AM
PM
o
o
o
o
AND/OR DEMOLITION START DATE:
Finish Date:
Work hours:
AM
PM
AM
PM
o
o
o
o
Yes
No
Yes
No
Working Weekends?
Working Evenings?
Tip: Ten day notification requires at minimum, ten (10) working days (Monday-Friday including holidays) prior to the commencement date. Ten days begin
with the US postmark date or date received in office by commercial services or hand delivery. IEPA, City of Chicago, and Cook County cannot accept
faxed copies, however, IDPH will accept faxed submissions. Phased projects will not be accepted.
IL532-1296
APC 430
Rev. 1/2013
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