150 Des Moines Street
Des Moines, IA 50309-1836
Date: Initials: Issued: Yes No
New Permit #: Issued date:
Exp. Date: Check #:
Violations: OSHA EPA
Debts: OSHA Wage Contractor
New Renewal Replacement Previous Asbestos Permit #: Expiration Date:
Application for Asbestos Permit
Contractor registration #
Business type: Sole Proprietor: Social Security number required Partnership Corporation Other:
Name of disposal site that will be used
Name and address of other asbestos business owned or operated by any Principals in your company currently or within the past three years
Former business name and address if changed within the past five years
Other states where the business has performed asbestos removal or encapsulation in the past five years
1. Respiratory protection program as described in 29 CFR 1926.1101(h) and 1910.134 as applicable.
2. Procedures for air sampling and personal monitoring.
3. Medical Surveillance policy, procedures, manual or program.
4. Blank ten-day notice form the business will use.
5. Copies of all citations, violations and penalties levied against the business within the past ten years by any federal, state or local
government agency for violations related to asbestos activity. Provide name and locations of the activity, date and a description of
how the allegations were resolved.
6. Describe any civil or criminal legal proceeding, lawsuit or claim, which has been filed or levied against the business or any principals
relating to asbestos activity within the past ten years.
7. Non-refundable $500.00 processing fee. Make check or money order payable to: Iowa Division of Labor
I certify that the information on this form and the attachments is true and accurate to the best of my knowledge; each employee or agent of
my business who will come into contact with asbestos or will be responsible for an asbestos project will first be licensed by the Iowa Division
of Labor for the particular activity performed; and the business will comply with all applicable standards for removal or encapsulation of
Signature of Chief Executive Officer or Designee Printed name Date
The Division of Labor may deny this application, or revoke or suspend your permit if you knowingly make false or fraudulent statements on this application or the attachments.
Criminal charges, forfeiture of your application fee, denial of future applications and a civil penalty up to $5,000.00 may result from obtaining or attempting to obtain a permit
through deceptive or fraudulent means.
Iowa Code sections 252J.8 and 272D.8 require that records of sole proprietors’ permits be maintained by social security number. If a sole proprietor fails to provide a valid social
security number, this application will be denied. Your social security number may also be shared with other governmental agencies.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
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