Deq Form Aac 2 PDF Details

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QuestionAnswer
Form NameDeq Form Aac 2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesr00, LOUISIANA, YY, OES

Form Preview Example

ASBESTOS NOTIFICATION OF DEMOLITION AND RENOVATION FORM AAC-2

 

 

 

LOUISIANA DEPARTMENT OF ENVIRONMENTAL QUALITY

 

 

 

 

 

 

 

 

 

OES - Air Permits Division, Manufacturing Section

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PO Box 4313, Baton Rouge, LA 70821-4313

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone (225) 219-3051 Fax (225)219-3156

 

Shaded boxes for LDEQ Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AI No.

 

 

 

 

 

Note: Incomplete or Illegible Applications Will Not Be Processed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ck/Voucher

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elec Transfer No.

 

 

I. Type of Notification: (check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amt Received:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

□ Original □ Revised □ Canceled

 

□ Additional

□ Annual (Maintenance)

 

 

 

 

Postmark Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADVF No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

II. Type of Operation: (check one)

□ DEMO □ RENO □ ORDERED

 

 

 

 

 

 

 

(Please note original ADVF no. if a rev.)

 

 

 

 

 

 

 

 

 

No. ADVFs

 

 

 

□ EMERGENCY □ NEGATIVE DECLARATION

 

 

 

 

 

 

 

 

 

 

 

Requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. FACILITY DESCRIPTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Project Designer La. Accred. No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address:

 

 

 

 

 

 

City:

 

 

 

 

State:

 

Zip Code:

 

Parish:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Site Location: (Building no., Name, Floor, Room No. Etc.)

 

Telephone No.

 

 

 

 

Building Size:

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No. of Floors:

 

 

 

Age in Years:

 

Present Use:

 

 

 

 

 

 

 

Prior Use:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inspection Date: (MM/DD/YY)

 

 

 

 

 

 

 

 

IV. IS ASBESTOS PRESENT: (Circle One)

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inspector’s Name:

 

 

 

 

 

 

 

 

 

 

Inspector’s Accreditation No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure including analytical method, if appropriate, used to detect the presence of asbestos material:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

V. APPROXIMATE AMOUNT OF ASBESTOS INCLUDING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMOVAL TIMES:

 

 

RACM/ CATEGORY I & II

 

 

RACM - UNIT OF

 

NONFRIABLE ACM NOT

 

 

(Check One)

 

 

TO BE REMOVED

 

 

MEASUREMENT

 

TO BE REMOVED DURING

 

 

□ Business Hours

□ After Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEMOLITION

 

 

(Describe Material-TSI, ceiling, transite etc)

 

(Type in Amount)

 

 

 

 

 

 

 

 

□ Weekends

□ Holidays

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAT I/ Cat II

 

 

 

RACM

 

 

CAT I/CAT II

 

 

 

UNIT

(packings, gaskets, resilient flooring,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

asphalt roofing, cloth, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Linear Ft.

Square Ft.

 

 

 

 

 

 

 

 

Pipes/ Surface Area

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Volume of RACM if off

 

 

 

 

 

 

 

 

 

Cubic Ft.

Cubic Yds.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of Facility Component

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VI. FACILITY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner Name:

 

 

 

 

 

 

 

 

 

Contact Name:

 

 

 

Telephone No.

 

 

 

Fax No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Removal Contractor Name:

 

 

LA Contractor’s License

On-Site Supervisor Name:

On-Site Supervisor Accreditation No.

 

 

 

 

 

 

 

 

No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

Contact:

 

 

 

 

 

 

 

Supervisor Exp. Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

Fax No.

 

 

 

 

 

 

 

State:

 

 

Zip Code:

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Operator:

 

 

 

 

 

 

 

 

 

 

Contact:

 

 

 

 

 

 

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form_7077_r00 10/26/05

NOTIFICATION OF DEMOLITION AND RENOVATION FORM –AAC-2 (continued)

VII. SCHEDULED DATES ASBESTOS REMOVAL (MM/DD/YY)

Start:

Complete:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VIII. SCHEDULED DATES DEMO/RENOVATION (MM/DD/YY)

 

Start:

 

Complete:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IX. WASTE TRANSPORTER TO LANDFILL

 

 

 

 

 

 

 

 

 

 

Name:

DEQ SW Transporter No.

Contact:

 

Telephone No.

 

 

 

 

 

 

 

 

(

 

)

 

 

 

Address:

 

City:

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X. WASTE TRANSPORTER (Other) i.e. CONTRACTOR TRANSPORTER TO DESIGNATED AREA

 

 

 

 

 

 

Name:

 

DEQ SW Transporter No.

Contact:

 

Telephone No.

 

 

 

 

 

 

 

 

(

 

)

 

 

 

Address:

 

City:

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

Physical Location of Drop Off Area:

 

City:

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XI. WASTE DISPOSAL SITE:

 

 

 

 

 

 

 

 

 

 

 

Name:

 

Contact:

 

Telephone No.

 

 

 

 

 

 

 

 

(

 

)

 

 

 

Physical Location:

 

City:

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

XII. IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, PLEASE IDENTIFY THE AGENCY REPRESENATIVE:

 

Name:

 

Title:

 

Authority:

 

 

 

 

 

 

 

 

 

 

 

Date of Order: (MM/DD/YY)

 

Date Ordered To Begin: (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XIII. FOR EMERGENCY RENOVATIONS:

 

 

 

 

 

 

 

 

 

 

Date and Hour of Emergency: (MM/DD/YY)

Description of the Sudden, Unexpected Event:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Justify circumstances that caused unsafe condition(s) or would cause equipment damage (or an unreasonable financial burden):

XIV. I certify that the above information is correct and that personnel performing asbestos Demolition or Renovation activities are trained and accredited in accordance with LAC 33:III.5151.F.3.h; and that the evidence of the required training will be available on the project site for inspection by LDEQ personnel.

____________________

__________________________________________

______________________

(Date)

(Signature of Owner or Operator/Contractor)

(Printed Name)

XIV. NEGATIVE DECLARATIONS ONLY : I certify that the above information is correct and that no asbestos or regulated asbestos containing material (RACM) is present or being removed.

____________________

__________________________________________

______________________

(Date)

(Signature of Owner or Operator/Contractor)

(Printed Name)

 

 

 

XV. Description of planned non-RACM Demolition or Renovation work and Methods to be used:

ADVF Fees:

$66

(Minimum of 10 working days notification given)

 

$99

for Emergencies (less than 10 working days notification given) No Voucher’s Will Be Accepted for Emergencies

No Fee for Negative Declarations.

REMIT TO: LDEQ/OES - Air Permits Division, Manufacturing Section, P. O. BOX 4313, BATON ROUGE, LA 70821-4313

Pursuant to R.S.40.1574 A&B, be advised that no construction or renovation can begin until the plans and specifications are reviewed by the Office of the State Fire Marshall or it is determined by that Office that plans are not required to be submitted.

Form_7077_r00 12/13/05 Page 2 of 2

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