Form Daqa-399-16 - Alternative Work Practice Request - Utah Division Of Air Quality
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1UTAH DIVISION OF AIR QUALITY
Postmark Date:
Initials:
195 North 1950 West, 4th Floor
P.O. Box 144820
Fee Received:
Check #/Credit Card:
Salt Lake City, UT 84114-4820
Alternative Work Practice Request
Fee Class
$100 Training Provider/Private Residence
$250 all other requests
Complete form fully, incomplete forms will not be approved. Allow at least one week for review.
(attach additional sheets as necessary)
1 Facility Name
Address
City
County
Zip Code
Part of Facility Involved
Dates of project
Cert #
2 Contractor
Address
City
State
Zip Code
Contact Person
Phone
3
What rule(s) will the alternative work practice replace?
(i.e. R307-801-13(3)(a) etc.)
4
Why is it not feasible to comply with the rule(s)?
5
What alternative and equivalent engineering controls will be used to control the release of asbestos fibers?
6
How are the alternative controls equivalent and how will they be monitored?
7
Submit a design of the affected portion of the project with sufficient diagrams, photographs and description to
define the scope of the alternate work practice and demonstrate that the alternate work practice is designed to
achieve control of asbestos equivalent to the rule. If the project is located in the interior space of public,
commercial or school buildings or residential structures greater than 4 units, the alternate work practices
must be designed by a Utah certified Project Designer.
Project Designer Name
Cert #
I certify that all the information in this request is true and correct.
Signature of Owner/Operator
Date
Print name and title of Owner/Operator
The approval of alternate work practices apply only to the rule(s) cited above and only to the specific project
and operator for which the request was submitted. All other requirements apply.
OFFICIAL USE ONLY
Date reviewed
Reviewers Initials
Approved:
Date
Rejection Comments:
DAQA-399-16
Revision 6/30/16
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