8. PROJECT DESIGNER ID#: 100- Name:
Complete Project Designer Name and License ID# if this project was designed by a Designer.
9. INSPECTOR ID#: 100- Name:
Tip: If procedure utilized is visual inspection, the inspector ID# must be provided.
10. PROCEDURE, INCLUDING ANALYTICAL METHOD, USED TO DETECT THE PRESENCE OF ASBESTOS
Name of Analytical Testing Laboratory:
11. ASBESTOS PROJECT MANAGER ID#: 100- Name:
12. AIR SAMPLING PROFESSIONAL ID#: 100- Name:
13. DISPOSAL SITE/LANDFILL NAME:
Address: Contact:
City: State: Zip: Phone:
14. WASTE TRANSPORTER/NAME:
Address: Contact:
City: State: Zip: Phone:
15. IS DEMOLITION ORDERED BY A GOVERNMENT AGENCY?
Yes
No
(If yes, a signed copy of Order must be attached.)
Government representative ordering the activity:
Title: Date of Order: Order Demolition Date:
16. FOR EMERGENCY RENOVATION:
Date and hour of emergency (mm/dd/yy): AM
PM
Describe sudden unplanned event. (example: boiler explosion) Explain how the event caused unsafe conditions or would cause equipment
failure or an unreasonable financial burden.
17. Description of procedures to be followed in the event that unexpected asbestos is found or previously non-friable asbestos
material becomes crumbled, pulverized or reduced to powder.
I certify that at least one representative trained in the provisions of 40 CFR Part 61, Subpart M, shall be on site during demolition or
renovation, having in his or her possession for inspection, evidence that the requisite training has been accomplished.
CERTIFICATE#
_____________________ NAMEOFTRAININGCOURSE __________________________________________
I certify the above information is correct.
____________________________________________________________________ _______________________
Signature of Demolition/Abatement Contractor or the Owner Date
Any person who knowingly makes a false, fictitious, or fraudulent material statement, orally or in writing, to the Illinois EPA commits a
Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony. (415 ILCS 5/44(h)).
Tip: All notification forms must be hand signed and dated. Hand stamps are not acceptable. IEPA and Cook County require original signatures on their notification forms. IDPH will
accept photocopies. All notifications submitted to IEPA and City of Chicago must be accompanied by the appropriate fee. There is no fee for notification to IDPH.
For Cook County Departmental Use Only.
Date Received CCDES: Post Mark Date: Input Into Computer:
Inspection Fee Received: Inspection Priority: Top
High
Low
Must be Inspected:
Date(s) of Inspections:
Inspection Report Attached: Yes
No
Violation Copies Attached: Yes
No
Printed by the Authority of the State of Illinois • W.O. #19-008 8/18 • IOCI19-101
The Illinois EPA is authorized to require, and you shall disclose, the information requested on this Agency form utilizing this form pursuant to the Illinois Environmental Protection Act (Act), 415 ILCS 5.
Failure to disclose the requisite information on this Agency form may result in your notification being denied, and/or penalties being imposed as provided for in the Act, 415 ILCS 5/42-45.
IL Environmental Protection Agency
P.O. Box 19276 MC 41
1021 N. Grand Ave East
Springfield, IL 62794-9276
$150 fee (Attach payment or Illinois
E-Pay receipt if paid electronically.)
IL Department of Public Health
525 W. Jefferson St.
Springfield, IL 62761
(FAX: 217-785-5897)
Email: DPH.Asbestos@illinois.gov
Cook County Department of Environment & Sustainability
no longer accepts the combined form and all notifications
must be filed with the Department at the web address below.
www.cookcountyil.gov/agency/environmental-control
Submit this form
to the appropriate
agencies:
www.ildceo.net/enviro
Chicago Department of Public Health
Permitting and Inspections
333 S. State St., Room 200
Chicago, IL 60604
Fees apply as follows:
Residential Unit with less than 4 units . . . $300.00**
Residential Units with 4 units or more . . . $450.00
Commercial/Industrial facilities. . . . . . . . . $600.00
** except that asbestos abatement in residential buildings with fewer than
two dwelling units are not subject to the notice and fee requirements.
