State Form 44593 - Notification Of Demolition And Renovation Operations - Indiana Department Of Environmental Management

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INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTIFICATION OF DEMOLITION AND RENOVATION OPERATIONS
State From 44593 (R2 / 8-99)
I.
Original
Revised *
Canceled
Courtesy
TYPE OF NOTIFICATION
(check one):
* Must include copy of notification which is being revised
II.
FACILITY INFORMATION (identify owner, removal contractor, demolition contractor, inspector, and project designer)
Owner:
Address:
City:
State:
Zip:
Contact:
Telephone #:
Removal
Demolition
Contractor:
Contractor:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Contact:
Phone:
Contact:
Phone:
IN License #:
Expiration:
(Required for asbestos projects at schools K – 12)
Inspector:
Project Designer:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
IN License #:
Expiration:
IN License #:
Expiration:
Phone:
Phone:
III.
(check one)
Renovation:
Emergency Renovation:
TYPE OF OPERATION
Intentional Burning:
Demolition:
Ordered Demolition:
IV.
IS ASBESTOS PRESENT?
(check one)
YES:
NO:
V.
PROCEDURES, INCLUDING ANALYTICAL METHODS, IF APPROPRIATE. USED TO DETECT THE PRESENCE AND AMOUNT OF ASBESTOS MATERIAL
VI.
(Including Regulated ACM, Category I non-friable Category II non-friable ACM)
APPROXIMATE AMOUNT OF ASBESTOS
Non-friable Asbestos Material
Non-friable Asbestos Material
Regulated
To be removed
Not to be removed before demolition
ACM to be removed
Category I
Category II
Category I
Category II
Pipes (LnFt)
Surface Area (SqFt)
Total Volume (CuFt)
on/off Components
VII.
SCHEDULED DATES OF ASBESTOS STRIPPING/REMOVAL:
Start:
End:
VIII.
Start:
End:
Start:
End:
SCHEDULED DATES OF RENOVATION:
DEMOLITION:
IX.
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:
Age:
Present Use:
Prior use:
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