NOTIFICATION OF DEMOLITION AND RENOVATION
Operator Project # Postmark Date Received Notification #
I. Type of notification (O=Original, R-Revised, C=Cancelled):
II. FACILITY INFORMATION (Identify owner, removal contractor and other operators):
OWNER NAME:
Address:
City: State: Zip:
Contact: Tel:
REMOVAL CONTRACTOR:
Address:
City: State: Zip:
Contact: Tel:
OTHER OPERATOR:
Address:
City: State: Zip:
Contact: Tel:
III. TYPE OF OPERATION (D=Demo, R=Renovation, E=Emer. Renovation)
IV. IS ASBESTOS PRESENT? (yes/no)
V. FACILITY DESCRIPTION (Include building name, number and floor or room number)
Bldg. name:
Address:
City: State: County:
Site Location:
Bldg. size: No. floors: Age in years:
Present use: Prior use:
VI. PROCEDURE, INDLUCING ANALYTICAL METHOD, IF APPROPRIATE, USED TO DETECT THE PRESENCE OF ASBESTOS MATERIAL:

VII. APPROXIMATE AMOUNT OF ASBESTOS INCLUDING:

1. Regulated ACM to be removed
2. Category I ACM not removed
3. Category II ACM not removed

 RACM to be removed Nonfriable Asbestos Material not to be removed Indicate Unit of Measurement Below
Category I Category II Unit
Pipes       Ln Ft: Ln M:
Surface area       Sq Ft: Sq M:
Vol RACM Off Facility Component       Cu Ft: Cu M:
VIII. SCHEDULED DATES ASBESTOS REMOVAL (MM/DD/YY) Start:                              Complete:
IX. SCHEDULED DATES DEMO/RENOVATION (MM/DD/YY) Start:                                   Complete: