U.S. EPA NOTIFICATION OF DEMOLITION AND RENOVATION
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Operator Project #
Postmark
Date Received
Notification #
I.
Type of Notification (check one):
Original
Revised
Canceled
II.
Facility Description
Building Name: ____________________________________________________________________________________________
Address: _________________________________________________________________________________________________
City: __________________________________
State: __________ Zip Code: _____________
County: ______________
Site Location : _____________________________________________________________________________________________
Building Size (square feet): __________________________
# of Floors: ________________
Age in Years: __________
Present Use: _______________________________________
Prior Use: ___________________________________________
Type of Operation (check one):
III.
Demo
Ordered Demo
Renovation
Emergency Renovation
Fire Training
Is Asbestos Present? (check one):
IV.
Yes
No
V.
Facility Information
Owner Name: ______________________________________________________________________________________
Address: ___________________________________________________________________________________________
City: ____________________________________________
State: _______________
Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
Removal Contractor Name: __________________________________________________________________________
Address: __________________________________________________________________________________________
City: ____________________________________________
State: _______________
Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
Other Operator (demolition/general): __________________________________________________________________
Address: ___________________________________________________________________________________________
City: ____________________________________________
State: _______________
Zip Code: _______________
Contact: ___________________________________ Telephone: (____)__________________ Fax: _________________
VI.
Procedure, including analytical methods, employed to detect the presence of and to estimate the quantity of RACM and
Category I and Category II non-friable ACM:
VII. Approximate Amount of Asbestos Materials:
Non-friable Asbestos Material
Non-friable Asbestos Material
RACM to be Removed
to be Removed
NOT to be Removed
Category I
Category II
Category I
Category II
Pipes (linear feet)
Surface Area (square feet)
Facility Components (cubic feet)
VIII. Scheduled Dates Demolition or Renovation:
Start:
Complete:
IX.
Dates for Asbestos Removal (MM/DD/YY)
Start:
Complete:
Days of the Week:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours of Operation: