Form 7077 R03 – Fill Out and Use This PDF

Louisiana Department of Environmental Quality

OES – Public Participation and Permit Support Division, Notifications and Accreditations Section

PO Box 4313, Baton Rouge, LA 70821-4313

Phone (225) 219-3244 Fax (225) 219-3310

Boxed Area for LDEQ Use

Only

AI No.

Note: Please type and complete all appropriate information

No. of ADVFs Requested:

Ck/Voucher

Emergency

Revision - ADVF no(s) to be Revised ___________

Canceled - ADVF no _________

Elec Transfer No.

I. Type of Notification: (check only one box)

Check if AAC-2 is for Nonscheduled Operations for repair or

Amt Received:

*Original

Additional-Latest ADVF no issued_____

maintenance less than 1 cubic yard of RACM per operation

Annual (Maintenance) Note Total Vol. Sec V as bin size

Postmark Date:

Disposal Only (work performed in _____

year)

ADVF No.

II. Type of Operation: (check only one box)

Check being demolished under an order of a state or

DEMO (RACM or *if structure contains no RACM)

RENO

local government agency

Check/Voucher Date

RENO & DEMO (RACM removal & subsequent demo)

Government Ordered

(Complete Sec. XIV)

III. FACILITY DESCRIPTION *

Facility Name:

Project Designer La. Accred. No (schools &

state bldgs only).

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:

IV. IS ASBESTOS PRESENT: *

YES

NO

Inspection Date: (MM/DD/YY)

Known or Assumed Asbestos

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

*NONREGULATED ACM NOT

(Check Applicable Times)

TO BE REMOVED

TO BE REMOVED PRIOR TO

Business Hours

After Hours

DEMOLITION * (if applicable)

Weekends

Holidays

RACM

CAT I/CAT II

CATEGORY I

(packings, gaskets, resilient/vinyl/asphalt)

DESCRIBE MATERIAL TO BE

TSI

Ceiling

VAT

Transite

Piping

Type of Non-Regulated Asbestos

REMOVED

Fireproofing

VAT

Asphalt Roofing

Other______________

Other_____________

Other_________________

RACM - UNIT OF MEASUREMENT

Linear Ft.

Square Ft.

Total Volume of all RACM

Amount of Non-Regulated Asbestos

(Type in Amount)

_____________ Cubic Yards (mandatory)

Asbestos Removal Contractor Name:

LA Contractor’s License

On-Site Supervisor Name:

On-Site Supervisor Accreditation No.

No.

Mailing Address:

Fax No.

Contact:

Supervisor Exp. Date:

(

)

City:

State:

Zip Code:

Telephone No.

Email:

(

)

Name:

DEQ SW Transporter No.

Contact:

Telephone No.

(

)

Address:

City:

State:

Zip Code:

Email:

XII. SOLID WASTE TRANSPORTER ONLY IF TAKEN TO OFFSITE PREMISES AND STORED PRIOR TO DISPOSAL (RACM ONLY)

Name:

DEQ SW Transporter No.

Contact:

Telephone No.

(

)

Address:

City:

State:

Zip Code:

Name:

Contact:

Telephone No.

(

)

Physical Location:

City:

State:

Zip Code:

Name:

Title:

Authority:

Date of Order: (MM/DD/YY)

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

Note: Copy of Order must be attached to this

Notification.

Date

and

Hour

of

Emergency:

Description of the Sudden, Unexpected Event that must immediately be attended to:

(MM/DD/YY)

____________________

__________________________________________

______________________

(Date)

(Signature of Owner or Operator/Contractor)

(Printed Name)

____________________

__________________________________________

______________________

(Date)

(Signature of Owner or Operator/Contractor)

(Printed Name)

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 Notification of Demo containing No RACM (Negative Declaration) may be faxed – Fax # 225-219-3310.