ࡱ> '`  bjbjLULU .?.?'C0000000D...8/\`/LD$0l$2$2$2$2<4>55P$h8!E0/>44"/>/>!00$2$2fs@s@s@/>0$20$2s@/>s@s@00s@$20 %f1.>ps@\|0s@3?s@0s@,*66`8s@9D8;*6*6*6!!@X*6*6*6/>/>/>/>DDD ('DDD('DDD000000 NEW APPLICATION FOR LICENSING AS AN ASBESTOS ABATEMENT CONTRACTOR OR IN-HOUSE ASBESTOS ABATEMENT UNIT Complete all sections of the application either by hand printing in ink or typing in the gray areas. Print out and sign the completed application and mail to Maine DEP with the appropriate application fee. Attach additional sheets as necessary. 1. Applicant:Company Name FORMTEXT  Company Address FORMTEXT  City FORMTEXT  State FORMTEXT  Zip FORMTEXT      Company Phone Number FORMTEXT  e-mail address FORMTEXT  Previous License Number (if applicable): FORMTEXT  Responsible Person: FORMTEXT  Title FORMTEXT      Is the applicant licensed or certified an asbestos contractor in another state?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, where: FORMTEXT  License or Registration Number: FORMTEXT  2. Contractor Categories: check only oneA)FULL FORMCHECKBOX Includes all abatement activities with no restrictionsB)LIMITED FORMCHECKBOX  Roofing - ACM roofing including transite roof shingles FORMCHECKBOX  Siding - Exterior ACM cementitious materials FORMCHECKBOX  Demolition by Large Equipment - with intact ACM flooringC) FORMCHECKBOX  In-House Asbestos Abatement Unit To perform asbestos contractor, consultant and/or laboratory activities solely within property owned or leased by the entity.3. APPLICATION REQUIREMENTS: Applicants for an Asbestos Abatement Contractor or In-House Asbestos Abatement Unit license must provide sufficient information to demonstrate that it meets the requirements of Chapter 425.4.B, including: A. A written worker protection program, including a respiratory protection program which conforms with the requirements of OSHA's Respiratory Protection Standard (29 CFR 1910.134, effective April 8, 1998); B. A medical monitoring program that conforms to the requirements of OSHA's Asbestos Standard for Construction (29 CFR 1926.1101, effective August 10, 1994), which includes the identity of the occupational health clinic utilized, number of employees enrolled in the program, and locations of employee exposure records; C. A list of all asbestos associated citations and notices of violation received in the United States during the last two years including the name of the issuing agency or department, the final disposition of such citation or notice, and, if the applicant's principal owner or operator or officer has received an asbestos associated citation or notice while owning or operating another company in the previous two years, a list of those violations; D. A list of states in which the applicant holds a license, certification, accreditation, or any other approval for asbestos abatement activity; E. A copy of the applicant's standard operating procedures containing detailed summaries of standard procedures for removal, monitoring, clearances, design and inspection, including a clear description of procedures to be followed if unexpected ACM is found or if previously intact stable ACM becomes friable during handling; * Limited licensees must submit standard operating procedures specific to their activities. F. A sign-off form acknowledging receipt of bulk sampling and project monitoring disclosures; G. Proof of access to a licensed asbestos disposal site; H. Proof that the applicant's employees engaged in asbestos abatement activities are certified pursuant to the requirements of this Chapter; I. A list of the names of the applicant's owner(s) or operator(s), principal(s), and officer(s); J. A list of all other entities, performing asbestos abatement activities or asbestos associated activities, of which the applicant, owner or operator(s), principal(s), or officer(s) is an owner or operator, principal or officer; K. A list of all names (or acronyms) by which the applicant's firm is known or under which it does business; L. Any information requested by the Department for purposes of determining the proficiency and adequacy of the applicant's standard operating procedures; M. Proof that at least one employee is a certified Asbestos Abatement Project Supervisor (or trained as a competent person for roofing, exterior cementitious, or demolition by large equipment projects); and N. A statement affirming that applicable state asbestos rules and regulations, including the Standards of Conduct and recordkeeping requirements of these rules, will be met. 4. RECORDKEEPING REQUIREMENTS: A. An Asbestos Abatement Contractor must maintain documents set forth below at its principal place of business or at an archive facility approved in advance by the Department, in a form which is easily retrievable by project. B. An Asbestos Abatement Contractor must submit a statement affirming that the following documents will be made available to the Department within 24 hours of request: * The name, address, and Department certification number for each of its employees engaged in asbestos abatement activities, including dates of employment; * Identification, by name and Department certificate number for each of its employees engaged in asbestos abatement activities, including dates of employment; * Copies of all correspondence between the Asbestos Abatement Contractor or its agent and any asbestos regulatory agency, including but not limited to letters, notices, citations received, and any notifications made by the contractor pursuant to this Chapter; * Documents required to be maintained under any other applicable federal, state or local laws or regulations; * Documents including, but not limited to, receipts, showing dates, locations and amounts of asbestos waste involved, the identification of the source of the asbestos waste, the disposal site, and the transporter; * Copies of consultant and laboratory reports provided to the Asbestos Abatement Contractor regarding the project design, on-site project monitoring records, and release of the regulated area including documenting the successful completion of the visual evaluation and air clearance sampling requirements; * Individual project records specified below. C. A statement must be submitted affirming that the Asbestos Abatement Contractor maintains the following documents at the abatement work site throughout the duration of such activity, and will make the documents immediately available to the Department upon request: * A company form signed by the company and each employee attesting that each employee has been trained in and is knowledgeable of company standard operating procedures before performing asbestos activities. * A current copy of the rules, Chapter 425 "Asbestos Management Regulations" (Effective date: April 3, 2011) * A copy of the site-specific asbestos abatement project design; * A listing of all employees, by name, social security number and Department certification number, who are assigned to the project; * A listing of each of the subcontractors involved in the asbestos portion of the project; * A Department certification card for each on-site employee involved in the project, or copies of current OSHA training for employees certified-by-rule; * A daily sign-in/out log clearly identifying each employee involved in the on-going project by name and Department certification number, identifying the length of time each spent at the project location; * Records of all on-site air monitoring including personal samples required by 29 C.F.R. 1926.1101, and project documentation; * A copy of the project notification, including variance(s) granted in accordance with these regulations by the Department; and * A copy of the form signed by the building owner or owner's agent acknowledging receipt of the bulk samples and/or project monitoring disclosures, if applicable. 5. ENFORCEMENT ACTIONS: Has there been any enforcement action(s) taken against the company with respect to asbestos abatement activities during the past year?YES FORMCHECKBOX NO FORMCHECKBOX If YES, include the name of the agency taking the action and copies of all correspondence relating to the enforcement action. 6. FEE: The application must include a non-refundable cashier's, certified, or company check in the amount of $650 dollars made payable to the Maine Environmental Protection Fund. Note: If there are not sufficient funds to cover the check or credit card transaction an insufficient funds fee will be assessed by the Department in accordance with State of Maine laws and policies. Until that insufficiency is resolved (by money order or bank check), the Department will not accept any additional checks or credit card transactions from the party including checks for project notifications. 7. SIGNATURE: I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED THE INFORMATION SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS THERETO AND THAT, BASED ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION, I BELIEVE THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. I AM ALSO AWARE THAT ALL ASPECTS OF ASBESTOS ABATEMENT ACTIVITIES ARE SUBJECT TO INSPECTION AT ANY TIME BY THE MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION. 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