Georgia Notification Form – Fill Out and Use This PDF

GEORGIA PROJECT NOTIFICATION FORM

FOR ASBESTOS RENOVATION, ENCAPSULATION, OR DEMOLITION

USE AN ATTACHMENT TO PROVIDE ADDITIONAL INFORMATION FOR ANY SECTION WHEN NEEDED TO PROVIDE COMPLETE

DETAILS.

DO NOT LEAVE ANY SECTION BLANK – INSERT UNKNOWN OR N/A IF NEEDED.

SECTION 1A - TYPE OF NOTICE (USE THE APPROPRIATE CHECKBOX TO INDICATE THE TYPE OF NOTICE YOU ARE SUBMITTING)

฀

ORIGINAL - INITIAL

฀

REVISION #_______

SECTION 1B - TYPE OF PROJECT

฀ CHECK IF SECTION REVISED

฀

RENOVATION/ABATEMENT ONLY

฀ RENOVATION/ABATEMENT PRIOR TO DEMOLITION

฀

ENCAPSULATION

฀

DEMOLITION ONLY

฀

JOINT DEMOLITION/RENOVATION

฀

ORDERED DEMOLITION

฀

EMERGENCY

฀ COURTESY (FOR NON-FRIABLE PROJECTS OR UNDER TRIGGER

QUANTITY PROJECTS ONLY!!!)

SECTION 2 – SITE INFORMATION

฀ CHECK IF SECTION REVISED

PROJECT NAME:

PROJECT ADDRESS:

PROJECT CITY:

ZIP:

COUNTY:

NEAREST MAJOR INTERSECTION:

BLDG SIZE IN SQ. FT:

AGE OF BUILDING IN YEARS:

NUMBER OF FLOORS IN BUILDING:

SPECIFIC LOCATION IN BUILDING OF ASBESTOS BEING REMOVED:

SECTION 3A – ABATEMENT CONTRACTOR

฀ CHECK IF SECTION REVISED

ASBESTOS REMOVAL CONTRACTOR:

CONTRACTOR’S STREET ADDRESS:

COMPANY CERTIFICATE #:

CITY:

STATE:

ZIP:

PHONE:

FAX:

GA LICENSED AGENT:

GA AGENT’S ID:

EXPIRES:

CELL PHONE:

3B – DEMOLITION CONTRACTOR

฀ CHECK IF SECTION REVISED

DEMOLITION CONTRACTOR:

DEMOLITION CONTRACTOR’S STREET ADDRESS:

SECTION 4 – ACM INFORMATION* Required for Compliance of Georgia Rules					฀ CHECK IF SECTION REVISED
IS ASBESTOS PRESENT? ฀ YES	฀ NO ฀ UNKNOWN			฀ FRIABLE		฀ NON-FRIABLE			฀ BOTH
DID AN AHERA ACCREDITED INSPECTOR INSPECT THIS SITE?			฀	YES			฀ NO		฀ ASSUMED ASBESTOS
INSPECTOR NAME:							INSPECTOR PHONE:
ACCREDITATION COURSE:		CERTIFICATE NUMBER:					EXPIRES:
SECTION 5 – WORK SCHEDULES (10 WORKING DAY ADVANCE NOTIFICATION REQUIRED FOR NON-EMERGENCY NOTIFICATIONS!)
					฀ CHECK IF SECTION REVISED
ABATEMENT START DATE	ABATEMENT END DATE			WORK DAYS (MON-SUN)				WORK HOURS (EX : 7A – 4P)

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SECTION 6 – ACM AMOUNTS, TYPE CODES, AND FEE CALCULATION

฀ CHECK IF SECTION REVISED

FIRST, LOCATE THE MATERIAL TO BE REMOVED IN COLUMN A. COLUMN B SHOWS THE USUAL NESHAP CATEGORY FOR THE

MATERIAL. COLUMN C SHOWS THE CATEGORY THE MATERIAL WILL LIKELY BECOME DURING ABATEMENT, AND THAT IS THE CODE THAT SHOULD BE USED FOR COMPLETING THIS FORM. NOW, ENTER THE SQ. FT AND/OR L.F. AMOUNTS OF ACM TO BE ABATED DURING THIS PROJECT UNDER THE CORRECT HEADING ACCORDING TO TYPE IN COLUMN D, E, AND/OR F. THEN, LOCATE THE CORRESPONDING TYPE CODE(S) FOR THE MATERIAL(S) IN COLUMN G AND ENTER THE CODES IN THE SPACES PROVIDED BEFORE PROCEEDING TO THE FEE CALCULATION SECTION.

Column A

Column B

Column C

SF OR LF AMOUNT TO BE ABATED

Column

DURING PROJECT

G

USUAL NESHAP CATEGORY

WILL

LIKELY

Column D

Column E

Column F

ACM

ACM TYPE

Category

Category

BECOME

TYPE

RACM

Category I

Category 2

RACM

1

2

WHEN

CODE

ABATED

ASBESTOS ASPHALT SHINGLES

√

1 OR RACM

AAS

ASBESTOS CEMENT (TRANSITE) PANELS

√

√

2 OR RACM

ACP

ASBESTOS CEMENT (TRANSITE) ROOFING

√

√

RACM

ACR

ASBESTOS CEMENT (TRANSITE) SIDING SHINGLES

√

√

RACM

ACS

ASBESTOS FLASHING

√

√

1

AF

ASBESTOS GASKET

√

√

1 OR RACM

AG

BOILER INSULATION

√

RACM

BI

BUILT-UP ROOFING

√

1 OR RACM

BUR

COVE (BASEBOARD) MOLDING MASTIC

√

1

CM

CEILING PLASTER

√

RACM

CP

CEILING TILE

√

RACM

CT

DUCT SEAM MASTIC

√

1

DSM

DUCT VIBRATION DAMPENERS

√

√

1 OR RACM

DVD

EXTERIOR (OUTSIDE) DUCT INSULATION

√

√

RACM

EDI

FELT DUCT TAPE

√

RACM

FDT

FLOOR MASTIC

√

1

FM

FIREPROOFING

√

RACM

FP

FIREPROOFING AND OVERSPRAY

√

RACM

FPO

FLOOR TILE

√

1 OR RACM

FT

FLOOR TILE AND MASTIC

√

1 OR RACM

FTM

INTERIOR (INSIDE) DUCT INSULATION

√

√

RACM

IDI

JOINT COMPOUND ONLY

√

RACM

JC

LIGHT WEIGHT CONCRETE

√

√

RACM

LWC

OTHER: FLOOR LEVELING COMPOUND, CAULKING,

√

√

2 OR RACM

OTR

ETC.

PIPE INSULATION STRAIGHT RUNS

√

RACM

PI

PIPE INSULATION ELBOWS AND FITTINGS

√

RACM

PIE

RESILIENT FLOOR COVERINGS (SHEET FLOORING;

√

√

1 OR RACM

RFC

LINOLEUM)

ROOF MASTICS AND COATINGS

√

√

1

RMC

ROOFING SILVER COATING

√

1 OR RACM

RSC

TEXTURED CEILING

√

RACM

TC

TEXTURED CEILING PLASTER

√

RACM

TCP

TANK INSULATION

√

RACM

TI

WALL BOARD AND JOINT COMPOUND

√

RACM

WBJC

WINDOW GLAZING

√

√

1 OR RACM

WG

WALL PLASTER

√

RACM

WP

Row G: Enter the ACM Type Codes from Col. G for each Category Below.

Category 1

Category 2

RACM

Category 1: ____________________________________________________________________________

Total

Total

Total

Category 2: ____________________________________________________________________________

RACM: ________________________________________________________________________________

________

________

________

CALCULATING FEES

Row H. IS THIS A RESIDENTIAL PROJECT

฀

YES

(USE TOTAL FROM COLUMN F (RACM) TO COMPLETE THIS SECTION)

RESIDENTIAL FEE SCHEDULE: $0.10 PER LF/SF

RESIDENTIAL PROJECT

TOTAL FEES DUE AND PAYABLE NOW

OF FRIABLE ACM WITH MINIMUM FEE: $25 -

COLUMN F (RACM) TOTAL

X $0.10

H (B) $_____________________

MAXIMUM FEE: $50 PER RESIDENCE/ DWELLING

H (A). ___________SF/LF

EQUALS

(NOT TO BE LESS THAN $25 OR MORE THAN $50 PER

UNIT.

UNIT)

Row I. IS THIS A NON-RESIDENTIAL PROJECT

฀ YES

(USE TOTAL FROM COLUMN F (RACM) TO COMPLETE THIS SECTION)

	CHECK NUMBER ____________ FOR THE AMOUNT SHOWN IN THE TOTAL FEES DUE ABOVE.
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SECTION 7 - WASTE TRANSPORTER, DISPOSAL SITE, AND BUILDING OWNER INFORMATION

฀ CHECK IF SECTION REVISED

WASTE TRANSPORTERTRANSPORTER CONTACT PERSON: NAME

TRANSPORTER’S MAILING ADDRESS:

CITY:	STATE:	ZIP:	PHONE:	FAX:

All Detached Non-Friable and Friable ACM Must Go To an ACM Permitted Landfill.

DISPOSAL SITE					DI SPOSAL SI TE COUNTY:
NAME:
DISPOSAL SITE ADDRESS:
CITY:	STATE:		ZIP:					PHONE:		FAX:
PROJECT OWNER				OWNER’S REPRESENTATIVE:
NAME:
OWNER’S STREET ADDRESS:
OWNER’S MAILING ADDRESS (IF DIFFERENT):
CITY:	STATE:		ZIP:					PHONE:		FAX:
SECTION 8 - WORK METHODS: METHOD OF DEMOLITION AND/OR RENOVATION ACTIVITY (DESCRIPTION OF WORK PRACTICES,
ENGINEERING CONTROLS, AND CLEARANCE METHODS)			฀ CHECK IF SECTION REVISED
SECTION 9 - ADDITIONAL PROJECT INFORMATION		฀ CHECK IF SECTION REVISED
WILL ASBESTOS REMAIN IN THE PROJECT AREA?	฀ NO		฀ YES			฀		UNKNOWN
EXPLAIN ‘YES’ OR ‘UNKNOWN’:
IF NO ASBESTOS IS PRESENT, WAS THIS PROJECT PREVIOUSLY ABATED?						฀		NO	฀ YES	฀ UNKNOWN
PRIOR ABATEMENT COMPANY:								YEAR ABATED:
PRIOR COMPANY CONTACT PERSON:								PHONE:

CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT

฀ CHECK IF SECTION REVISED

I, THE UNDERSIGNED, CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF FEDERAL REGULATIONS (NESHAP/40 CFR PART 61 SUBPART M) WILL BE

ON THE PROJECT SITE DURING DEMOLITION AND/OR RENOVATION ACTIVITIES DESCRIBED IN THE NOTIFICATION. EVIDENCE THAT THIS PERSON AND ALL OTHER PROJECT PERSONNEL HAVE ACCOMPLISHED APPROPRIATE TRAINING AND TRAINING CERTIFICATES WILL BE AVAILABLE FOR INSPECTION DURING NORMAL BUSINESS HOURS AND ANYTIME REGULATED ACTIVITIES ARE BEING CONDUCTED ON SITE.

I FURTHERMORE UNDERSTAND THAT I AM RESPONSIBLE FOR THE ACCURACY AND COMPLETENESS OF THE INFORMATION SUBMITTED WITH THIS

NOTIFICATION AND I SHALL PROMPTLY SUBMIT REVISIONS, SUPPORTING DOCUMENTS, AND PROJECT FEES.

REPRESENTING: ฀ OWNER

฀ ABATEMENT CONTRACTOR ฀ DEMOLITION CONTRACTOR ฀ OTHER _________________

•REFER TO THE DETAILED INSTRUCTIONS WHEN IN DOUBT ABOUT PROPER COMPLETION OF ANY SECTION.

•NEVER LEAVE BLANK SPACES – INSERT ‘N/A’ OR ‘UNKNOWN’ FOR ANY BLANK WHERE YOU DO NOT HAVE THE INFORMATION REQUESTED.

•PRINT RESPONSES NEATLY AND LEGIBLY.

•ALWAYS KEEP A COPY OF THIS FORM FOR YOUR RECORDS, AND PROVIDE COPIES TO ALL OTHER INVOLVED PARTIES.

•EPD NO LONGER ACCEPTS ‘FAX ONLY DOCUMENTS’. SUBMIT THE ENTIRE FORM VIA MAIL.

•NEVER SUBMIT PROJECTS WHERE FEES ARE DUE WITHOUT ATTACHING THE REQUIRED FEE CHECK OR MONEY ORDER.

•NOTIFICATIONS WITH FEES MUST BE MAILED TO THE EPD ASBESTOS FEES POST OFFICE ADDRESS. NOTIFICATIONS WITHOUT FEES SHOULD BE MAILED DIRECTLY TO THE EPD OFFICE ADDRESS.

(ADDRESSES ARE ON THE FIRST PAGE.)

•DO NOT SUBMIT ‘TWO-SIDED’ PHOTO COPIES.

•If a Project Notification is submitted by someone other than the asbestos abatement or demolition contractor - such as the Consultant or Owner,

A REVISED NOTIFICATION MUST BE SUBMITTED BY THE CONTRACTOR TO WHOM THE PROJECT IS AWARDED BEFORE WORK BEGINS. THE CONTRACTOR MUST SIGN THE CERTIFICATION OF THE REVISED NOTIFICATION FORM.

IT IS YOUR RESPONSIBILITY TO SUBMIT THIS FORM ACCURATELY AND COMPLETLY AND INCLUDE BY ALL

APPLICABLE FEES.

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•CITY/ZIP/COUNTY - Complete all areas. YOU MUST LIST THE COUNTY.

•NEAREST MAJOR INTERSECTION - For example: “State Hwy 41 near Windy Hill Rd”; “South Houston Lake Rd near State Hwy 96”)

•BLDG SIZE IN SQ. FEET - Square foot measurement of the entire building (all floors and spaces) combined.

•AGE OF BLDG IN YEARS - Age of building in years.

•NUMBER OF FLOORS IN BUILDING - Total number of floors in building, including sub-basement, basement, mezzanine, attic, and penthouse. Each level that can be occupied should be counted as a separate floor.

•SPECIFIC LOCATION OF ASBESTOS BEING REMOVED - Provide specific area(s) of the structure that are being abated or demolished. For example: “Roof”, “Kitchen Floor”, “Steam Pipes in Basement”, “Throughout Building”, “Hallway”, “Floor Number _____”, “Room Number______”, etc).

SECTION 3 – PROJECT CONTRACTORS

3A – ABATEMENT CONTRACTOR – Name of the company that will perform the asbestos renovation/abatement.

•CONTRACTOR STREET ADDRESS – The actual physical location of the Asbestos Removal Contractor’s place of business. DO NOT USE A POST OFFICE BOX IN THIS SPACE!

•COMPANY CERTIFICATE NUMBER – The number issued on the contractor company certificate by the Georgia Lead-Based Paint and Asbestos Program.

•CITY/STATE/ZIP/PHONE/FAX – You must complete each space.

•LICENSED AGENTS NAME – Name of the person licensed by EPD as the Principal Agent for this company

•AGENT’S ID NUMBER – The agent’s number issued by EPD. Example: “50123”

•EXPIRES – The date on which the agent’s certificate expires.

•CELL PHONE – The cellular or pager number for the Principal Agent.

3B – DEMOLITION CONTRACTOR – Name of company performing work OTHER THAN asbestos removal.

•DEMOLITION CONTRACTOR’S STREET ADDRESS – The actual physical location of this Contractor’s place of business. DO NOT USE A POST OFFICE BOX IN THIS SPACE!

•CITY/STATE/ZIP/PHONE/FAX – You must complete each blank.

(If more than 2 Contractors are involved with the project, use a separate sheet as an attachment to provide additional information)

SECTION 4 – ASBESTOS CONTAINING MATERIAL(S) (ACM) INFORMATION

IS ASBESTOS PRESENT?

•YES – A thorough inspection for the presence of asbestos has been conducted and the written results indicate that asbestos IS present.

•NO – A thorough inspection for the presence of asbestos has been conducted and the written results indicate that asbestos IS NOT present.

•UNKNOWN – It is unknown if an asbestos inspection has been performed, or an inspection has been performed but the results are unknown at this time.

•FRIABLE – “Friable Asbestos-Containing Material” means any material containing more than 1 percent asbestos, by weight, and which when dry may be crumbled, pulverized, or reduced to powder by hand pressure or non-friable material that will be subjected to sanding, grinding, abrading or crushing.

•NON-FRIABLE – “Non-Friable Asbestos-Containing Material” means any asbestos-containing material that does not meet the definition of “FRIABLE”.

•BOTH – Both “Friable” and “Non-friable” materials are present on this project.

DID AN AHERA ACCREDITED INSPECTOR INSPECT THIS SITE?

Was the portion of the abatement project, or demolition area described in Section 2 of this form, thoroughly inspected by an AHERA Accredited Asbestos Inspector? Check ฀ the appropriate answer

•YES

•NO

•UNKNOWN

•ASSUMED ASBESTOS - A thorough inspection for the presence of asbestos HAS NOT been conducted but based on the type of material(s) being disturbed, the decision has been made to treat the material(s) as ACM.

•INSPECTOR NAME – Name of individual who performed the inspection.

•INSPECTOR PHONE – Number at which the Inspector may be reached, starting with area code.

•ACCREDITATION COURSE – Name of course taken to obtain ASBESTOS INSPECTOR accreditation. For example: “Asbestos Inspector Initial (AII)” OR “Inspector Refresher (AIR)”

•CERTIFICATE NUMBER – Number on the Asbestos Inspector Certificate of Course Completion issued by the Training Provider.

•EXPIRES – Expiration date on certificate issued by Training Provider.

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SECTION 5 – WORK SCHEDULES

IMPORTANT NOTICE: A 10 (TEN) WORKING DAY NOTIFICATION IS REQUIRED PRIOR TO COMMENCING ANY REGULATED

ASBESTOS ACTIVITY. (Exception: Valid Emergency Projects)

WORKING DAYS ARE CONSIDERED MONDAY THROUGH FRIDAY. A HOLIDAY FALLING ON THESE DAYS WILL BE COUNTED AS A

WORKING DAY. WORKING DAYS ARE COUNTED FROM THE DATE OF: US POST OFFICE POSTMARK DATE

FEDEX/UPS SHIPPING DATE

ELECTRONIC FILING OF PROJECT NOTIFICATION

NOTIFICATIONS POSTMARKED ON A SATURDAY OR SUNDAY DO NOT BEGIN THE 10 WORKING DAY NOTIFICATION PERIOD

UNTIL THE FOLLOWING MONDAY.

FOR ALL PROJECTS

Provide the project START date and END dates. NOTE: If the Consultant or Project Owner is submitting the project notification, and project dates are as yet undetermined, submit dates as TBD (To Be Determined). THE ABATEMENT OR DEMOLITION CONTRACTOR WHO RECEIVES THE CONTRACT MUST SUBMIT A REVISION TO UPDATE THE PROJECT DATES BEFORE WORK BEGINS.

WORK DAYS - Provide actual days of the week on which work will be performed – NOT the number of days worked per week. For example: “M, Tu, Th” or “M-F”

WORK HOURS - Provide the actual times of the day the crew will be on site – NOT the number of hours worked per day. For example “7A – 4P” or “5P – MIDNIGHT”

PHASED PROJECTS - If multiple buildings/structures are involved, break project into Phases, and identify project dates per Phase. Use an additional page to described phased project start and stop dates and work hours in detail.

SECTION 6 – ACM TYPES INFORMATION AND FEE SCHEDULE

Use this section to identify the type and total quantity of asbestos that will be disturbed during this project and calculate fees owed based on your findings. All ACM’s identified in Section 4 must be described completely here.

ACM TYPE(S)

•Step 1 - Locate the type of ACM you will be disturbing in COLUMN A. Use the Category 1, 2 and RACM headings in COLUMN B to determine the material’s current status, then locate the category the material will MOST LIKELY BECOME as a result of your abatement activities in COLUMN C.

•Step 2 - Show the combined LINEAR FOOT (LF) and/or SQUARE FOOTAGE (SF) of the material to be disturbed in COLUMN D, E, or F, depending on the determination made from the code in COLUMN C

•Step 3 - In COLUMN G, circle the corresponding ACM type code for any material amount listed in COLUMN(S) D, E, or F. In ROW G2, enter the type code(s) in the space(s) labeled CAT 1, CAT 2, and RACM.

•Step 4 – Total COLUMNS D, E, and F and insert the total(s) in the appropriate space(s) provided.

DEFINITIONS:

CATEGORY 1 NON-FRIABLE ACM includes asbestos-containing packing, gaskets, resilient floor covering, mastics, and asphalt roof products that contain greater than 1% asbestos. Category 1 materials that will likely become friable as a result of removal activity must be listed in the RACM category.

CATEGORY 2 NON-FRIABLE ACM includes any asbestos-containing material, excluding Category 1 non-friable ACM, These are primarily the asbestos-cement products. Category 2 materials that will likely become friable as a result of removal activity must be listed in the RACM category.

RACM (Regulated Asbestos-Containing Material) means friable asbestos containing material, Category 1 non-friable ACM that has become friable, Category 1 non-friable ACM that will be or has been subjected to sanding, grinding, cutting, or abrading, or Category 2 non-friable ACM that has a high probability of becoming or has become crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the course of demolition or renovation operations

FEE CALCULATION SECTION

Step 1 - Use the check box to indicate whether the project is RESIDENTIAL (ROW H.) or NON-RESIDENTIAL (ROW I.).

Step 2 - Place the total from COLUMN F on the correct line provided in either “BOX H (A). – RESIDENTIAL” or “BOX I (A) – NON-RESIDENTIAL”. Step 3 – Multiply the number in BOX H (A) or I (A) by $0.10 (Ten Cents - 10¢) and place the resulting amount in line H (B) or I (B)

MINIMUM AND MAXIMUM FEES:

RESIDENTIAL PROJECTS: Residential projects are subject to a minimum fee of $25 and a maximum fee of $50 per dwelling unit.

NON-RESIDENTIAL PROJECTS: Non-residential projects are subject to a minimum fee of $25 and a maximum fee of $1,000.

DEFINITIONS:

RESIDENTIAL PROJECT: A residential dwelling means any family residence or apartment building with four or fewer dwelling units.

NON-RESIDENTIAL PROJECT: A non-residential project means any project conducted on any building that would fall outside the guidelines

established by the definition of a residential dwelling. I.E.: any non-residential structure, or any residential structure with five or more dwelling units.

IF FEES ARE DUE FOR ANY PROJECT, SHOW THE CHECK NUMBER IN THE SPACE PROVIDED.

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SECTION 7 – BUILDING OWNER, WASTE TRANSPORTER, AND DISPOSAL SITE INFORMATION

WASTE TRANSPORTER: Complete all areas

NAME OF COMPANY

CONTACT NAME: Name of person at Transport Company to call, if necessary.

ADDRESS/CITY/STATE/ZIP/PHONE/FAX

DISPOSAL SITE INFORMATION

WASTE DISPOSAL SITE NAME: Name of Landfill.

DISPOSAL SITE COUNTY: Provide County name.

ADDRESS/CITY/STATE/ZIP/PHONE/FAX: Complete all areas.

BUILDING OWNER

OWNER OF PROJECT SITE/FACILITY: Name of legal owner of facility/property.

OWNER’S REPRESENTATIVE: Name of person (other than Contractor) acting on behalf of Owner, particularly if completing & submitting this form.

OWNER’S STREET ADDRESS: For service of legal process if required. OWNER’S MAILING ADDRESS if different than the street address. CITY/STATE/ZIP/PHONE/FAX Complete all areas.

TELEPHONE NUMBER: Number at which Contact person may be reached, starting with area code.

SECTION 8 – WORK METHODS

Enter the method(s) of demolition and/or renovation activity and a description of work practices and engineering controls to be used on this project. Describe fully what types of abatement and/or demolition activities are going to take place, the method(s) of removal and/or demolition that will be used, and controls in place to prevent asbestos emissions. Attach a separate sheet of paper if more room is needed to answer this section.

FOR EXAMPLE:

“Wet spud bar and chemical removal of FT M with critical barriers. 1 negative air. Visual clearance only”;

“Wet spud bar removal of ACS over 6 mil plastic on ground. Place in plastic lined roll of dumpster. Visual clearance only” “Demo with front-end loader. Push down, wet, and machine load into 30 CY roll of dumpster”

SECTION 9 - ADDITIONAL PROJECT INFORMATION

WILL ASBESTOS REMAIN IN THE PROJECT AREA? Please answer “YES”, “NO”, or “UNKNOWN”, and explain a YES or UNKNOWN answer.

IF NO ASBESTOS IS PRESENT, WAS THIS THE RESULT OF A PREVIOUS ABATEMENT?

IF THE PROJECT WAS PREVIOUSLY ABATED, PROVIDE ALL REQUESTED INFORMATION FOR THE PRIOR ABATEMENT COMPANY.

CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT

PROVIDE ALL REQUESTED INFORMATION - DO NOT LEAVE ANY SPACES BLANK AND INCLUDE SIGNATURE

PRINTED NAME - Print or type full name of person submitting form.

PHONE: Phone number of the person submitting the Project Notification.

SIGNATURE - The person submitting this form must submit with their signature.

DATE - Date project notification is signed

REPRESENTING - Check the appropriate title:

฀OWNER - Owner of Facility in which project is being performed

฀ABATEMENT CONTRACTOR – A Georgia Licensed Asbestos Abatement Contractor

฀DEMOLITION CONTRACTOR – Demolition Contractor

฀OTHER CONTRACTOR – A contractor representing another trade involved on the project. For example: “General Contractor,”

“ Sub Contract or,” or “ Consult ant .”

COMPANY NAME: Name of company submitting the Project Notification.

ADDRESS: Complete the mailing address including street, city, state and zip code.

NOTE: If a Project Notification is submitted by someone other than the asbestos abatement or demolition contractor - such as the Consultant or Owner - in order to start the 10 working day notification period while the contract is out for bid, A REVISED NOTIFICATION MUST BE SUBMITTED BY THE CONTRACTOR TO WHOM THE PROJECT IS AWARDED BEFORE WORK BEGINS. THE CONTRACTOR MUST SIGN THE CERTIFICATION AREA OF THE REVISED NOTIFICATION FORM.

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