Fillable NOTIFICATION FORM FOR ROAD CONSTRUCTION AND (Bay Area Air Quality Management District)

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NOTIFICATION FORM FOR ROAD CONSTRUCTION AND (Bay Area Air Quality Management District)

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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
NOTIFICATION FORM FOR ROAD CONSTRUCTION AND
MAINTENANCE OPERATIONS
The Bay Area Air Quality Management District must be notified in writing at least fourteen (14)
days prior to the initiation of any road construction or maintenance activity (§ 93105 (d)(1)(B),
Title 17, CCR).
Please complete the following form and submit it to the District at least two
weeks before the project begins. Failure to submit this form in a timely manner may result in
a violation of the Asbestos ATCM, which may be subject to substantial penalties.
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. Detailed Project Information
Type of Project: (Check all that applies)
Road Construction
Road Maintenance
Railway Construction
Trenching / Utilities Work
Other (please describe)
For District Use Only
Date
Rec’d
File #
Press here to clear form
ASBESTOS DUST MITIGATION PLAN APPLICATION
BAY AREA AIR QUALITY MANAGEMENT DISTRICT 5 375 Beale Street, Ste. 600, San Francisco, CA 94105
Page 2 of 2
062518
3. Detailed Site Information
Areas and Facilities within a quarter mile (400 meters) of the Project: (Check all that applies)
Residential
Commercial
Industrial
Rural
Hospital / Nursing Home
School
Park / Playground
Other (please describe)
4. Additional Information
The following information MUST be included:
Map(s) clearly indicating:
If available, please attach the
following information:
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
REQUIREMENTS FOR ROAD CONSTRUCTION AND MAINTENANCE
Equipment and operations must not cause the emission of any dust that is visible crossing
the project boundaries; and
The following dust control measures must be implemented during any road construction or
maintenance activity:
Unpaved areas subject to vehicle traffic must be stabilized by being kept adequately wetted,
treated with a chemical dust suppressant, or covered with material that contains less than 0.25
percent asbestos; AND
The speed of any vehicles and equipment traveling across unpaved areas must be no more
than fifteen (15) miles per hour unless the road surface and surrounding area is sufficiently
stabilized to prevent vehicles and equipment traveling more than 15 miles per hour from
emitting dust that is visible crossing the project boundaries; AND
Storage piles and disturbed areas not subject to vehicular traffic must be stabilized by being
kept adequately wetted, treated with a chemical dust suppressant, or covered with material
that contains less than 0.25 percent asbestos; AND
Activities must be conducted so that no track-out from any road construction project is visible
on any paved roadway open to the public.
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NOTIFICATION FORM FOR ROAD CONSTRUCTION AND (Bay Area Air Quality Management District)

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Completed 27 January 2021

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