Demolition/renovation Notification Form
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1
2Asbestos Demolition/Renovation Notification Form
N.H. Department of Environmental Services – Air Resources Division
(Please see reverse side for instructions)
Waiver #:_______________
New Notification: _______ or Revision: ________________
(for Emergency D/R only)
Fee Enclosed: $____________________
1. Site Owner:____________________________
2. Contractor:_____________________
Address:_______________________________
Address:________________________
________________________________
________________________
Phone:_________________________________
Phone: _________________________
Contact Person:_________________________
Contact Person:__________________
3. Building Name:___________________________
4. Demo
( )
Reno
( )
Address:_________________________________
Pickup/Disposal
( )
________________________________
Emergency D/R
( )
5. Building Description:
Bldg. Size:_____ # Floors____Age:______Current Use______________Prior Use_____________
6. Amount of ACM present:
Amount to be abated:
___________linear feet friable
_________________
7. Start Date:__________
___________square feet friable
_________________
End Date:__________
___________linear non-friable
_________________
Hours of Operation:__________
___________square non-friable
_________________
Days of Operation:___________
8. Location in building of the ACM listed:
_________________________________________________________________________________
9. Site Supervisor:____________________________________________________________________
10. Transporter & address:_______________________________________________________________
_________________________________________________________________________________
11. Final Disposal site & address:_________________________________________________________
_________________________________________________________________________________
12. Nature of methods to be used:_________________________________________________________
_________________________________________________________________________________
13. Inspection conducted by:_____________________________________________Date:____________
14. Unusual work practices to be employed:________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
15. Authority ordering demo (if applicable):________________________________________________
____________________________________________________________________________________
16. I certify that the above information is correct:_________________________
______________
Signature
Date
Mail notification form and fee payment to: Asbestos Program, NHDES-ARD
29 Hazen Drive, PO Box 95
Concord, NH 03302-0095
Questions: (603) 271-1370, Steven Cullinane
Form Revised 11-01-08
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