Certification Application For Asbestos Company Form - Department Of Environmental Quality
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1
2STATE OF UTAH
OFFICIAL USE ONLY
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF AIR QUALITY
195 North 1950 West, P.O. Box 144820
Salt Lake City, Utah 84114-4820
CERTIFICATION APPLICATION FOR
By_______ Fee________ Check# _______
ASBESTOS COMPANY
COMPANY INFORMATION:
Name of
Company:_______________________________________________________________________________________
Mailing
Street
Address: ___________________________________
Address:___________________________________________
_____________________________________
___________________________________________
Phone:
_____________________
Fax:
_______________________
Email: __________________________
Who controls interest in the company?
Who are the officers and directors of the company?
Name:
Title:
Name:_____________________________
_________________________ _________________________
Mailing
Address: ___________________________
_________________________ _________________________
____________________________
_________________________ _________________________
***If more space is needed, please make a note and attach a separate sheet***
Has any of the above information changed since the last certification? ______________________
APPLICATION FOR:
[ ]
Initial Certification
[
]
Annual Recertification
If Recertification, Certification Number _____________
-OVER-
READ AND SIGN THE FOLLOWING STATEMENT:
As an authorized representative of this asbestos company, I certify that:
1.
Only individuals trained in accordance with UAC R307-801-4, will be used to perform asbestos projects. At
least one person trained in accordance with UAC R307-801-4 will be responsible for the construction of the
containment, supervision, and inspection of each asbestos project conducted by the company. Only certified
management planners, project designers and inspectors will be used while performing these functions.
2.
All Federal, State, and local rules and regulations dealing with asbestos will be followed by the company at all
times.
3.
To the best of my knowledge, all information given with this application is correct.
________________________________ ______________________________ ____________________
Signature of Authorized Representative
Title of Representative
Date
___________________________________
Printed Name of Authorized Representative
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