Haw. Code R. § tit. 11, subtit. 1, ch. 501, fig. 3

Current through November, 2024

Figure 3 - Asbestos Notification of Demolition and Renovation June 1, 1998

Postmark:	Received:		Notification #:
I. Type of notification: O=original R=revised C=cancelled
II. Type of operation: D=Demolition R=Renovation OD=Ordered Demolition ER=Emergency Renovation
III. Facility information
Owner name:
Address:
City:		State:		Zipcode:
Contact person:				Telephone #:
Removal contractor:				License #:
Address:
City:		State:		Zipcode:
Contact person:				Telephone #:
Other operator:
Address:
City:		State:		Zipcode:
Contact person:				Telephone #:
IV. Is asbestos present (y/n):
Inspector's name: Certification #: State of certification:
V. Facility description (Include building number, floor and room number)
Building name:
Address:
City:		State:		Zipcode:
Site location:
Building size (sq. ft.):		# Floors:		Age:
Present use:		Prior use:
VI. Procedure used to detect the presence of asbestos
Laboratory name: Analytical method

Figure 3. Page 2 of 3

Asbestos Notification of Demolition and Renovation

June 1, 1998

VII. Specify the nature of the asbestos material (TSI, surfacing, VAT, miscellaneous):
Amount of asbestos, including: 1. RACM to be removed 2. CAT I left in place, and 3. CAT II left in place	RACM to be removed	Nonfriable ACM not to be removed
		Category I	Category II
Pipes (linear ft.)
Surfacing (square ft.)
Facility components (cu. ft.)
VIII. Scheduled asbestos abatement dates Start (mm/dd/yy): Finish (mm/dd/yy) Circle workdays and times: weekdays: daytime nighttime weekends: daytime nighttime
IX. Scheduled renovation/demolition dates Start (mm/dd/yy): Finish (mm/dd/yy) Circle workdays and times: weekdays: daytime nighttime weekends: daytime nighttime
X. Description of the planned renovation/demolition work and methods to be used:
XI. Description of the work practices and engineering controls to be used to prevent emissions of asbestos from the work-site: Project designer name: Certification #: State:
XII. Waste transporter #1
Name:
Address:
City:		State:	Zipcode:
Contact Person:		Telephone:
Waste transporter #2
Name:
Address:
City:		State:	Zipcode:
Contact Person:		Telephone:

Figure 3. Page 3 of 3 Asbestos Notification of Demolition and Renovation

June 1, 1998

XIII. Waste disposal site:
Facility Name:	Telephone:
Address:
City:	State:	Zipcode:
XIV. For demolition ordered by a government agency, please identify:
Name:	Title:
Authority (Agency):
Date of order (mm/dd/yy):	Date ordered to begin (mm/dd/yy):
XV. For emergency renovations:
Date and time of emergency Date (mm/dd/yy): Time: (a.m./p.m.)
Description of sudden, unexpected event and the damage caused:
Explanation of how the event caused an unsafe condition or would cause equipment damage or an unreasonable financial burden:
Person contacted for approval at the Noise, Radiation & Indoor Air Quality Branch: Name: Date (mm/dd/yy): Time: (a.m./p.m.)
XVI. Description of procedures to be followed in the event that unexpected asbestos is found or previously nonfriable asbestos material becomes crumbled, pulverized or reduced to powder:
XVII. 1 certify that an individual trained in the provisions of Hawaii administrative rules chapter 11-501, and certified as a contractor/supervisor, will be on-site during the entire renovation and/or demolition and evidence that the required training has been accomplished for this and all workers will be available at the work-site. ______________________ ______________ Signature of owner/operator Date (mm/dd/yy):
XVIII. I certify that the information on this notification is correct. ______________________ ______________ Signature of owner/operator Date (mm/dd/yy):

Haw. Code R. tit. 11, subtit. 1, ch. 501, fig. 3

June 1, 1998