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Fill a Valid Illinois Apc 430 Form

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The Illinois APC 430 form is a crucial document for notifying the Illinois Environmental Protection Agency about demolition and renovation activities that may involve asbestos. This form must be completed in its entirety to ensure compliance with federal regulations under the National Emission Standards for Hazardous Air Pollutants (NESHAP). Key sections of the form include details about the type of notification—whether original, revised, or canceled—and the nature of the operation, such as renovation, demolition, or emergency work. It requires specific information about the facility, including its name, address, and the presence of asbestos-containing materials. Additionally, the form outlines scheduled dates for demolition and asbestos removal, as well as information on contractors involved in the project. A certification section ensures that a trained representative will be on-site during the work, and it mandates a filing fee to be submitted with the notification. Failure to provide complete and accurate information can lead to violations, making adherence to the guidelines essential for all parties involved in the demolition or renovation process.

Example - Illinois Apc 430 Form

REC. NO. NOTIFICATION OF DEMOLITION AND RENOVATION

IL 532 1296 APC 430

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:

 

County:

 

 

State:

 

ZIP:

 

 

 

 

 

 

 

Location of Asbestos Containing Material (ACM) in structure:

 

 

 

 

 

 

 

 

 

 

 

 

Bldg. Size:

 

# of Flrs.

 

Age:

Present Use:

 

 

 

 

 

 

 

 

 

 

Prior Use:

 

Future Use (Demo):

 

 

 

 

 

 

 

 

 

 

4. IS ASBESTOS PRESENT?

Y N

5. WORK HOURS:*

a.m.

 

p.m.

 

 

 

 

 

6. SCHEDULED DATE DEMOLITION:

 

Start:

Complete:

 

 

 

 

7. SCHEDULED DATE ASBESTOS REMOVAL:

Start:

Complete:

 

 

 

 

 

8. REGULATED ASBESTOS

 

NONFRIABLE ASBESTOS NOT

NONFRIABLE ASBESTOS TO BE

 

TO BE REMOVED (Demolition):

REMOVED:

 

 

CONTAINING MATERIAL TO BE

 

 

 

 

 

 

 

 

REMOVED (RACM):

 

CATEGORY I

 

CATEGORY II

CATEGORY I

 

CATEGORY II

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pipes (Ln. Ft.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Surface Area (Sq. Ft.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Volume (Cu. Ft.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. ASBESTOS REMOVAL CONTRACTOR:

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State, Zip:

 

Contact:

 

 

Phone:

 

 

 

 

 

 

 

 

 

10. DEMOLITION CONTRACTOR:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State, Zip:

 

Contact:

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

11. OWNER NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State, Zip:

 

Contact:

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

12. WASTE TRANSPORTER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

State, Zip:

 

Contact:

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

13. WASTE DISPOSAL SITE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

 

 

 

 

 

 

 

 

State, Zip:

 

Landfill Permit #:

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-AGENCY USE ONLY-

 

 

 

Date Received:

Input to ACTS:

 

To Region 1 2 3

 

 

 

 

 

 

 

 

Post Mark Date:

To Cook/City:

 

Champaign:

 

LaSalle:

 

 

 

 

 

 

 

Springfield:

Rockford:

 

 

Moline:

 

Marion:

 

 

 

 

 

 

 

 

 

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.)

 

 

Governmental representative ordering the activity:

 

 

 

 

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

▼ PDF

Document Breakdown

Fact Name Description
Form Purpose The Illinois APC 430 form is used to notify the Illinois Environmental Protection Agency of planned demolition and renovation activities involving asbestos.
Governing Law This form is governed by the National Emission Standards for Hazardous Air Pollutants (NESHAP), specifically 40 CFR Subpart M, Section 61.145.
Required Sections All sections of the form must be completed to avoid potential notice violations.
Notification Types There are three types of notifications: Original (O), Revised (R), and Canceled (C).
Operation Types The form includes various operation types such as Renovation (R), Demolition (D), and Emergency Renovation (E).
Asbestos Presence The form requires a declaration of whether asbestos is present in the structure.
Contractor Information Contact details for the asbestos removal contractor and demolition contractor must be provided.
Filing Fee A filing fee of $150 is required for each initial 10-working day notification.
Emergency Renovation For emergency renovations, the form requires details about the unexpected event that necessitated the work.
Signature Requirement The form must be signed by the owner or operator, certifying the accuracy of the provided information.
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