ࡱ> '` Tbjbj .W,dddgggghi" rrrrs{z'~DFFFFFF$_hǤ~jdssjrrcEEE\8rdrDEDEE2LLd<ri P3g .py0.E=E\<Ed<4EMtjj5$'@&@x4"  Asbestos Project Notification 2009 RevisionState of Maine Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 TEL (207) 287-2651 FAX (207) 287-6220 FORM N Page 1 of 3  Important Notice: The notification submitter must send a complete notification including any applicable fee which is postmarked at least 10 calendar days or received by the Department at least 5 working days prior to the start of an asbestos abatement project. This notification must be typewritten or easily legible. An incomplete notification is not acceptable & therefore not of record. 1. Project* Code  FORMTEXT       (Assigned by notification submitter) *See definition of project at Chapter 425.1.CCCType of Notification  FORMCHECKBOX  Standard (O)  FORMCHECKBOX  Facility O&M (Annual)  FORMCHECKBOX  Emergency (E)  FORMCHECKBOX  Courtesy (Not Regulated) Type of Activity  FORMCHECKBOX  Demolition (D)  FORMCHECKBOX  Renovation (R)  FORMCHECKBOX  Repair Variances (Check all that apply)  FORMCHECKBOX  Non-Standard (NS)  FORMCHECKBOX  Standard (S)  FORMCHECKBOX  Notification Waiver (10 day)  Asbestos Contractor Name  FORMTEXT       Address  FORMTEXT       City _ FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Contact  FORMTEXT       TEL  FORMTEXT       FAX  FORMTEXT      Facility Owner Name  FORMTEXT       Mailing Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Contact  FORMTEXT       TEL  FORMTEXT       FAX  FORMTEXT      Facility Location (Where removal is to take place) BLDG Name  FORMTEXT       Floor and/or Rm.#  FORMTEXT       Physical Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       Facility Description Present Use  FORMTEXT       Prior Use  FORMTEXT       BLDG Size  FORMTEXT       No. Floors  FORMTEXT       BLDG Age  FORMTEXT      Notification Fees (Required fees must accompany notification)  FORMCHECKBOX  $100.00 = ACM amounts 100 SqFt/100 LnFt to less then 500 SqFt/2,500 LnFt.  FORMCHECKBOX  $150.00 = ACM amounts 500 SqFt/2,500 LnFt or greater and less than 1,000 SqFt/5,000 LnFt  FORMCHECKBOX  $300.00 = ACM amounts 1,000 SqFt/5,000 LnFt or greater  FORMCHECKBOX  Not Required or Not Included (Complete Block #9A)9A. Notification Fee Not Included  FORMCHECKBOX  Single family home exemption  FORMCHECKBOX  ACM amount less than 100 SqFt/100 LnFt  FORMCHECKBOX  Fees paid quarterly (Non-Scheduled O&M only)  FORMCHECKBOX  BGS exemptionProject Work Hours  FORMTEXT       AM to  FORMTEXT       PM (Show actual hours) Weekdays (Check all that apply)  FORMCHECKBOX  M  FORMCHECKBOX  T  FORMCHECKBOX  W  FORMCHECKBOX  T  FORMCHECKBOX  F Weekend (Check all that apply)  FORMCHECKBOX  Sat  FORMCHECKBOX  SunScheduled Dates for Asbestos Project Project Start Date (mm/dd/yy)  FORMTEXT       Project Completion Date  FORMTEXT       ACM Removal Dates (from)  FORMTEXT       (to)  FORMTEXT      Asbestos Project Notification Proj. Code  FORMTEXT       2009 RevisionState of Maine Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 TEL (207) 287-2651 FAX (207) 287-6220 FORM N Page 2 of 3Asbestos (ACM) Removal ME DEP USE ONLY Postmark/ FAX/ hand delivered _________________________ Date Received ____________ Check # ________________ NESHAP _______________ State ___________________ Variance ________________ ACM TypeAmountMeasurement FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT       FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT       FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT       FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT       FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT       FORMTEXT       FORMTEXT      SqFt  FORMTEXT       LnFt  FORMTEXT      13. Demolition (complete as applicable)  FORMCHECKBOX  Ordered demolition (structurally unsound) by State or local government (attach copy of order and name of professional engineer who determined building structurally unsound)  FORMCHECKBOX  All other demolitions Demolition Dates:  FORMTEXT       to  FORMTEXT      Procedure Used to Detect Presence of Asbestos Testing  FORMCHECKBOX  Assumed Positive  FORMCHECKBOX  Tested Positive Method  FORMCHECKBOX  PLM  FORMCHECKBOX  TEM Sampled By  FORMTEXT       (Print Name) Company  FORMTEXT       Project Clearance Visual evaluation by: (Air Monitor (if known) and Company)  FORMTEXT       Air Clearance by: (Air Monitor (if known) and Company)  FORMTEXT        Note: Whenever building materials are assumed to contain asbestos, signed bulk sampling disclosure forms must be at the asbestos abatement project site and available for review by the Department. 16. Asbestos Abatement Methods (check all that apply & submit variance request (Form V) if required)  FORMCHECKBOX  Regulated area with containment consisting of 2-layers 4 mil poly on walls & ceiling & 2 layers 6 mil poly on floors  FORMCHECKBOX  Regulated area with containment consisting of 1-layer 6 mil poly on walls & ceiling & 2 layers 6 mil poly on floors  FORMCHECKBOX  Regulated area with Exclusion zone  FORMCHECKBOX  Intact flooring demo by heavy equipment  FORMCHECKBOX  Multiple non-contiguous glovebags (variance required)  FORMCHECKBOX  Adhesive by grinding or bead blasting  FORMCHECKBOX  Contiguous glovebags less than 30 Ln/ft (variance required)  FORMCHECKBOX  Enclosure  FORMCHECKBOX  Wrap & cut- TSI in good condition (no containment)(variance required)  FORMCHECKBOX  Encapsulation  FORMCHECKBOX  Wrap & cut- TSI not in good condition (containment required)  FORMCHECKBOX  Roofing removal by mechanical saws/cutters  FORMCHECKBOX  Flooring by mechanical equipment/ice scrapers/pry bars  FORMCHECKBOX  Other (specify)  FORMTEXT       17. 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Code:  FORMTEXT       2009 RevisionState of Maine Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 TEL (207) 287-2651 FAX (207) 287-6220 FORM N Page 3 of 3Certification (Notification Submitted by) I certify that to the best of my knowledge, the information contained in this notification is true and accurate, and that the asbestos abatement contractor will be/has been contracted to implement work practices as required by Maine DEP Chapter 425, the Asbestos Management Regulations. _________________________________________________  FORMTEXT       Signature Print Name Date  FORMTEXT       Mailing Address  FORMTEXT       City  FORMTEXT       State  FORMTEXT       Zip  FORMTEXT       TEL  FORMTEXT       FAX  FORMTEXT       20. Emergency Notification (oral notification must be made within 1 working day of the emergency) Complete when a waiver to the standard notification period is requested for an emergency asbestos removal project which is necessitated by a sudden, unexpected event such as non-routine failures of equipment or by actions of fire and emergency medical personnel pursuant to duties within their official capacities. Written emergency notification must be received by the Department as soon as possible, but no later than 72 hours after the emergency. Detailed Explanation (Include the date and hour on which the emergency occurred)  FORMTEXT       _____________________________________________  FORMTEXT       Signature (Emergency Notification requested by) Print Name Date  FORMTEXT       MEDEP Action on Emergency Notification  FORMCHECKBOX  APPROVED  FORMCHECKBOX  DISAPPROVED (by) _______________________________________ (date)_________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 21. Notification Waiver Request (must be received by MEDEP at least 24 hours prior to the start of the project) Complete when a waiver to the standard notification period is requested when reasonable planning & foresight could not have predicted the event & other notification procedures would not suffice to protect public health & the environment. Examples include discovering additional asbestos-containing material during a renovation or demolition for which an asbestos inspection was conducted (e.g., within a wall cavity or plumbing chase), a public health threat exists or will develop (e.g. clean up following a fiber release episode), or unforeseeable circumstance (e.g., boiler & associated piping/valves failure). 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