Fillable Atcm Exemption App - ADMP Exemption Application

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Atcm Exemption App - ADMP Exemption Application

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BAY AREA AIR QUALITY MANAGEMENT DISTRICT
375 Beale Street, Suite 600
San Francisco, California 94105
(415) 771-6000
ASBESTOS AIRBORNE TOXIC CONTROL MEASURE FOR CONSTRUCTION, GRADING,
QUARRYING, AND SURFACE MINING OPERATIONS
§ 93105, Title 17, California Code of Regulations
ASBESTOS ATCM EXEMPTION APPLICATION
1. Company and Project Information
Company Name and Address Project Location
Name Location
Address Address
City/State Zip City/State Zip
Contact Start Date
Phone Fax Estimated Completion Date
2. Exemption Requested
Indicate the type of exemption(s) that is (are) potentially applicable:
Geologic Evaluation Exemption (Complete FORM A)
Remote Location Exemption (Complete FORM B)
Emergency Road Repair Exemption (Complete FORM C)
2. Detailed Project Information
Type of Project: (Check all that applies)
Road or Railway Construction
Road Maintenance
Housing Development
Commercial Property Development
Trenching / Utilities Work
Other (please describe)
For District Use Only
Date
Rec’d
File #
Press here to clear form
ASBESTOS ATCM EXEMPTION APPLICATION
BAY AREA AIR QUALITY MANAGEMENT DISTRICT 375 Beale Street, Ste. 600, San Francisco, CA 94105
FORM A: GEOLOGIC EVALUATION
The District may provide an exemption from the Asbestos ATCM for any property that lies within the
boundaries of a geographic ultramafic rock unit as indicated by the referenced geologic maps. This
exemption would be granted if a registered geologist has conducted a geolog
ic evaluation of the
property and determined that no serpentine or ultramafic rock is likely to be found in the area to be
disturbed. Before an exemption can be granted, the owner/operator must provide a copy of a report
detailing the geologic evaluation to the District for consideration.
A1. Registered Geologist Information
Geologist’s Name Company Name (if applicable)
Address Phone
City Fax
State Zip License Number
A2. Detailed Site Information
(Check all that applies)
Physical Site Inspection
Offsite geologic evaluation of adjacent property
Evaluation of existing geological maps and studies
of the site and surrounding area
Geologic Maps developed for the site and vicinity
Identification of geologic units, rock and soil types,
and other geologic features that may indicate the
presences, etc.
Subsurface investigation
Other information (please describe)
A3. Additional Information and Materials
(Check all that applies)
A description of any sampling procedures used
A description of any analytical procedures used
Rock samples collected and archived
The geologic evaluation report prepared by a registered geologist.
FORM B: REMOTE LOCATION
The District may provide an exemption from the requirements of Asbestos ATCM affecting
construction and grading operations for any activity that will occur at a remote location. A remote
location is defined as any location that is at least one (1.0) mile from the location of a receptor.
"Receptor" includes, but is not limited to, any hospital, school, day care center, work site, business,
residence, and permanent campground. The distance to the nearest receptor must be measured
from the outermost limit of the area to be disturbed or road surface, whichever is closer.
B1. Detailed Site Information
Areas and Facilities within two (2.0) miles of the Project: (Check all that applies)
Residence
Commercial Business
Industrial Site
Work Site (unrelated to this project)
Hospital / Nursing Home
School
Park / Playground
Permanent Campground
Other (please describe)
B2. Additional Information
The following information MUST be included:
Map(s) clearly indicating:
If available, please attach the
following information:
Map(s) indicating location of
potential receptors
Property lines / boundaries
Rights of way / easements
Areas to be cleared or graded
Trenching areas
Excavation sites
Storage areas / piles
Track-out control
Staging areas for removal
Truck routes
On-site parking lots
Geologic Information
Topographical Maps
Meteorological Data
ASBESTOS ATCM EXEMPTION APPLICATION
BAY AREA AIR QUALITY MANAGEMENT DISTRICT 375 Beale Street, Ste. 600, San Francisco, CA 94105
FORM C: EMERGENCY ROAD REPAIR NOTIFICATION
The Asbestos ATCM allows a delay in notification when construction of a road or firebreak, or a road
repair is necessary due to a landslide, flood, or other emergency or to mitigate a condition that
constitutes an imminent hazard to the public. The owner/operator shall notify the District no later than
the next business day of the action taken and the condition establishing the applicability of this
subsection.
Pursuant to the Asbestos ATCM for Construction and Quarrying operations, Section 93105(d)(3)(A),
Title 17, CCR, I, , do hereby notify the Executive Officer
of the Bay Area Air Quality Management District that an emergency road repair was initiated at the
location listed above due to the following reason:
Landslide
Flood
Other .
This location is either within the boundaries of a geographic ultramafic rock unit or is known to have
ultramafic rock, serpentine rock or asbestos present.
This repair resulted in at least acres disturbed to complete the repair. In
completing this repair, the applicable control measures listed in Section 93105(d)(1)(B) of the
Asbestos ATCM are being implemented during the repair.
PRINT NAME HERE
DESCRIBE
SIGNATURE
PRINT NAME / TITLE OR POSITION
DATE
DISTURBED AREA
ASBESTOS ATCM EXEMPTION APPLICATION
BAY AREA AIR QUALITY MANAGEMENT DISTRICT 375 Beale Street, Ste. 600, San Francisco, CA 94105
062518
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Completed 27 February 2020

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