Form Hea 5121 - Prior Notification Of Asbestos Hazard Abatement Project

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D
N
W
T
S
O
OT
RITE IN
HIS
PACE
Postmark
Date Received
Notification No.
By
Ohio Department of Health
Prior Notification of Asbestos Hazard Abatement Project
Read carefully all the instructions and questions prior to completing the notification form.
1. Notifications including check shall be typed and sent to the Ohio Department of Health, Attn: Revenue Processing,
P.O. Box 15278, Columbus, Ohio 43215.
2. Checks shall be made payable to: Treasurer, State of Ohio, for the amount of sixty-five dollars ($65.00).
3. Any licensed asbestos hazard abatement contractor who performs any asbestos hazard abatement projects within the State of
Ohio shall submit prior notifications to the Director at least ten business days before beginning each planned asbestos hazard
abatement project as required by Chapter 3701-34 of the Ohio Administrative Code.
■ ■
■ ■
4. Type of notification
original
revision number________
revised line(s) number ______
______
______
______
■ ■
■ ■
■ ■
emergency
blanket
cancellation
5. Type of abatement involving at least 50 linear feet or 50 square feet
■ ■
■ ■
■ ■
■ ■
■ ■
removal
repair
encapsulation
enclosure
renovation
6. Owner name
Address
City
State
ZIP
Contact
Contact telephone number
(
)
7. License number
Abatement Contractor
Expiration
Address
City
State
ZIP
Contact
Telephone number
(
)
8. Certification number
Name of asbestos hazard abatement specialist for project
Expiration
9. Project information—Building name
Address
City
State
County
Site location (specific)
10. Project description
■ ■
■ ■
■ ■
surfacing
mechanical
other
Type of asbestos material
■ ■
■ ■
■ ■
pipe
boiler
other
Asbestos removal from
■ ■
■ ■
■ ■
AFD
glove bag
other
Engineering controls
11. Estimate of asbestos containing material
linear feet
square feet
12. Abatement dates
completion
set up
abatement
(acm work only)
Hours of operation
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Days of the week
13. Approved landfill—Name
EPA permit number
City
State
Telephone number
14. Name of person filing this notice
Date
HEA 5121 (Rev. 8/03)

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