REC. NO. NOTIFICATION OF DEMOLITION AND RENOVATION
Illinois Environmental Protection Agency |
P.O. Box 19276, Springfield, IL 62794-9276 |
Rev.06/03 |
THIS INFORMATION IS REQUIRED; NESHAP-40CFR-SUBPART M-61.145, Rev. Nov. 20, 1990
ALL SECTIONS MUST BE COMPLETED TO AVOID NOTICE VIOLATION
1.TYPE OF NOTIFICATION (O-Original/R-Revised/C-Canceled):
2.TYPE OF OPERATION (R-Renovation/D-Demo/A-Annual/O-Ordered Demo/E-Emergency Renovation):
3.FACILITY DESCRIPTION (Building Name):
Address:
City: |
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County: |
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ZIP: |
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Location of Asbestos Containing Material (ACM) in structure: |
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Bldg. Size: |
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# of Flrs. |
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Age: |
Present Use: |
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Prior Use: |
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Future Use (Demo): |
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4. IS ASBESTOS PRESENT? |
Y N |
5. WORK HOURS:* |
a.m. |
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p.m. |
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6. SCHEDULED DATE DEMOLITION: |
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Start: |
Complete: |
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7. SCHEDULED DATE ASBESTOS REMOVAL: |
Start: |
Complete: |
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8. REGULATED ASBESTOS |
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NONFRIABLE ASBESTOS NOT |
NONFRIABLE ASBESTOS TO BE |
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TO BE REMOVED (Demolition): |
REMOVED: |
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CONTAINING MATERIAL TO BE |
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REMOVED (RACM): |
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CATEGORY I |
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CATEGORY II |
CATEGORY I |
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CATEGORY II |
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Pipes (Ln. Ft.) |
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Surface Area (Sq. Ft.) |
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Volume (Cu. Ft.) |
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9. ASBESTOS REMOVAL CONTRACTOR: |
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Address: |
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State, Zip: |
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Contact: |
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10. DEMOLITION CONTRACTOR: |
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Address: |
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State, Zip: |
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Contact: |
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11. OWNER NAME: |
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Address: |
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State, Zip: |
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Contact: |
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12. WASTE TRANSPORTER: |
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Address: |
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City: |
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State, Zip: |
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Contact: |
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13. WASTE DISPOSAL SITE: |
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Address: |
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City: |
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State, Zip: |
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Landfill Permit #: |
Phone: |
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-AGENCY USE ONLY- |
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Date Received: |
Input to ACTS: |
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To Region 1 2 3 |
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Post Mark Date: |
To Cook/City: |
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Champaign: |
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LaSalle: |
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Springfield: |
Rockford: |
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Moline: |
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Marion: |
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14.PROCEDURE, INCLUDING ANALYTICAL METHOD, USED TO DETECT THE PRESENCE OF ASBESTOS.
ILLINOIS LICENSE NUMBER OF INSPECTOR: NAME OF ANALYTICAL TESTING LABORATORY:
15.DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK:
METHODS TO BE EMPLOYED INCLUDING DEMOLITION OR RENOVATION TECHNIQUES.
16.DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS AT THE DEMOLITION OR RENOVATION SITE:
17. IS DEMOLITION ORDERED BY A GOVERNMENTAL AGENCY? |
Y N (If Yes, a signed copy of Order must be attached.) |
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Governmental representative ordering the activity: |
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Title: |
Date of Order: |
Ordered Demolition Date: |
18.FOR EMERGENCY RENOVATIONS: Date and Hour of Emergency:
Description of the Sudden, Unexpected Event (e.g. structure in danger of eminent collapse):
19.DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND OR PREVIOUSLY NONFRIABLE ASBESTOS MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO POWDER.
20.I CERTIFY THAT AT LEAST ONE REPRESENTATIVE, TRAINED IN THE PROVISIONS OF 40 CFR PART 61, SUBPART M, SHALL BE ON-SITE DURING DEMOLITION OR RENOVATION, HAVING IN HIS OR HER POSSESSION, FOR INSPECTION, EVIDENCE THAT THE REQUISITE TRAINING HAS BEEN ACCOMPLISHED.
I CERTIFY THE ABOVE INFORMATION IS CORRECT.
Signature of Owner/Operator Date
(Original Signature Only, Photocopy Not Valid)
A FILING FEE OF $150 MUST BE PAID WITH EACH INITIAL 10-WORKING DAY NOTIFICATION REQUIRED BY THE ASBESTOS NESHAP. MAKE CHECKS PAYABLE TO ILLINOIS EPA AND MAKE NOTATION THAT IT IS FOR THE 10-WORKING DAY NOTIFICATION FEE. CASH AND CREDIT CARDS ARE NOT ACCEPTABLE. IF THE FEE IS NOT SUBMITTED WITH THE NOTIFICATION, THE NOTIFICATION WILL BE DEEMED IMPROPERLY FILED.
*Not required under NESHAPS.
Mail this form to: IL Environmental Protection Agency, Attn: Asbestos Unit, P.O. Box 19276, Springfield, IL 62794-9276