X. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK, AND METHOD(S) TO BE USED:
XI. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS OF ASBESTOS AT THE
DEMOLITION OR RENOVATION SITE:
XII. WASTE TRANSPORTER #1
Name:
Address:
City: State: Zip:
Contact Person: Tel:
WASTE TRANSPORTER #2
Name:
Address:
City: State: Zip:
Contact Person: Tel:
XIII. WASTE DISPOSAL SITE
Name:
Address:
City: State: Zip:
Tel:
XIV. IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, PLEASE IDENTIFY THE AGENCY BELOW:
Name: Title:
Authority:
Date of Order (MM/DD/YY): Date Ordered to Begin (MM/DD/YY):
XV. FOR EMERGENCY RENOVATIONS:
Date and Hour of Emergency (MM/DD/YY):
Description of the sudden unexpected event:
Explanation of how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden:
XVI. DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND OR PREVIOUSLY
NONFRIABLE ASTESTOS MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO POWDER:
XVII. I CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF THIS REGULATION (40 CFR PART 61, SUBPART M) WILL BE ON-
SITE DURING THE DEMOLITION OR RENOVATION, AND EVIDENCE THAT THE REQUIRED TRAINING HAS BEEN ACCOMPLISHED BY THIS
PERSON WILL BE AVAILABLE FOR INSPECTION DURING NORMAL BUSINESS HOURS.
(Signature of Owner/Operator)
(Date)
XVIII. I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT:
(Signature of Owner/Operator)
(Date)
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
