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Asbestos 10-Day Notification Form
Abatement Contractor Name
Company Name
(optional)
Type of Notification
Original
(optional)
Revised
(optional)
Cancelled
(optional)
Scheduled Dates - Asbestos Removal
Start Date
Start Date: Date
Start Date: Time
End Date
End Date: Date
End Date: Time
Facility Description
Facility Address
Address
Address 2
(optional)
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
Building Name
Site Location (Floor or Room Number)
(optional)
Building Size
(optional)
# of Floors
# of Floors
(optional)
- None -
1
2
3
4
5
6
7
8
9
10
11
12
12+
Other…
Enter other…
(optional)
Year Constructed
(optional)
Year Constructed: Year
(optional)
Present Use (ex. Vacant)
(optional)
Prior Use
(optional)
Facility Contact Information
Facility Contact Name
First
Last
Contact Phone Number
Contact Email Address
(optional)
Approximate Amount of Asbestos
Approximate Amount of Asbestos
(optional)
Re-order
Asbestos Material
Quantity
Location
Weight
Operations
Asbestos Material
(optional)
Quantity
(optional)
Location
(optional)
Item weight
(optional)
Add more items
(optional)
more items
Quantity in Square Feet - The Total Surface Area of RACM to be Removed
(optional)
Re-order
Asbestos Cement Board
Ceiling Materials
Floor Materials
Roof Materials
Spray-on Materials
Window Glaze / Caulk
Other
Weight
Operations
Asbestos Cement Board
(optional)
Ceiling Materials
(optional)
Floor Materials
(optional)
Roof Materials
(optional)
Spray-on Materials
(optional)
Window Glaze / Caulk
(optional)
Other
(optional)
Item weight
(optional)
Attached Files
Attached Files
(optional)
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Emergency Renovation?
Emergency Renovation?
Yes
(optional)
No
(optional)
Date of the Emergency
(optional)
Date of the Emergency: Date
(optional)
Date of the Emergency: Time
(optional)
Description of the Emergency
(optional)
Explain how the event caused unsafe conditions or would cause equipment damage or an unreasonable financial burden. Please provide as much information as possible.
Certification
Certification
Required if asbestos is present.
I certify that an individual trained in the provisions of regulation 40 CFR Part 61, Subpart M (Asbestos NESHAP) will be onsite during
The demolition or renovation and evidence that require training has been accomplished by this person will be available for inspection
during normal business hours.
I certify that to the best of my knowledge all information is true and correct.
Signature
Sign above
Applicant Name
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
Middle
(optional)
Last
Suffix
(optional)
Signed Date
Leave this field blank
(optional)