Revised 11 December 2019
Maricopa County Air Quality Department
3800 N. Central Ave., Suite 1400, Phoenix, AZ 85012
Phone: 602-506-6010 Fax: 602-372-0587
Asbestos@maricopa.gov
NESHAP NOTIFICATION FORM FOR DEMOLITION AND RENOVATION
11. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT
ASBESTOS EMISSIONS
Adequately Wet Full Containment Critical Barriers/Negative Air Glove-Bag Leak-Tight Wrap
6-Mil Bags
Other (Please Specify):
12. SCHEDULED DATES FOR ASBESTOS REMOVAL
Start Date: Completion Date:
Days Worked (Check All That Apply):
M T
W Th F Sa Su
Day Shift Hours
Start: Stop:
Evening Shift Hours
Start:
Stop:
13. SCHEDULED DATES FOR DEMOLITION
Start Date: Completion Date:
Days Worked (Check All That Apply):
M T
W Th F Sa Su
Day Shift Hours
Start: Stop:
Eve Shift Hours
Start: Stop:
14. ASBESTOS WASTE TRANSPORTER #1
Name of Company:
Address: City/Town: State: Zip:
Contact Name: Phone: E-mail:
15. ASBESTOS WASTE TRANSPORTER #2
Name of Company:
Address: City/Town: State: Zip:
Contact Name: Phone:
E-mail:
16. ASBESTOS WASTE DISPOSAL SITE
Name of Company:
Address: City/Town: State: Zip:
Contact Name: Phone: E-mail:
17. FOR ORDERED DEMOLITIONS (40 CFR 61, §61.145(a)(3)), ATTACH A COPY OF THE AGENCY'S ORDERED DEMOLITION LETTER
Name: Title:
State or Local Gov't Agency: Authority:
Date of Order: Date Demolition Order to Begin:
18. FOR EMERGENCY RENOVATIONS (40 CFR 61, §61.145(a)(4)(iv))
When did the emergency occur?
Date: Time:
Description of Sudden, Unexpected Event:
Explanation of how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden:
19. DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED RACM IS FOUND OR
CATEGORY II NONFRIABLE ACM BECOMES CRUMPLED, PULVERIZED, OR REDUCED TO POWDER:
Stop Work
Notify Owner Revise Notification Follow 40 CFR 61, §61.145(c) Procedures
20. I CERTIFY THAT AT LEAST ONE AHERA CERTIFIED CONTRACTOR/SUPERVISOR WILL SUPERVISE THE
STRIPPING AND REMOVAL OF RACM AND THAT THE TRAINING CERTIFICATE WILL BE POSTED ON-SITE.
(Print Name of Owner/Operator) (Title) (Date)
(Signature of Owner/Operator)
21. CERTIFICATION OF INSPECTION BY AN AHERA CERTIFIED ASBESTOS BUILDING INSPECTOR
(Print Name of Inspector)
(Training Provider) (AHERA Certificate Number) (Expiration Date)
22. I CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT:
(Print Name of Owner/Operator) (Title)
(Signature of Owner/Operator) (Date)
Fee required for RACM removal at or above: 260 Linear Feet, 160 Square Feet, or 35 Cubic Feet. Demolition fee required for all NESHAP facilities. See Fee Schedule under
Rule 280, Section 312 and 313.2. One single family residence is exempt, two or more are regulated. References: Title 40, Code of Federal Register, Part 61, Subpart M,
Asbestos NESHAP §61.145(b). Arizona Revised Statutes, Title 49, §§49-421 & 471 et. Seq., and Arizona Administrative Code, Title 18, Chapter 2, Air Pollution Control,
Article II, §R18-2-1101. Maricopa County Air Pollution Control Regulations, Rule 370, §301.8
Maricopa County Air Quality NESHAP Coordinator: 602-506-670, Asbestos Resource Page
Send a Copy of Notification to: AZ Division of Occupational Safety & Health, 800 W. Washington St. Phoenix, AZ 85007 (602) 542-5795
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