Form SFN17987 "Asbestos Notification of Demolition and Renovation" - North Dakota

What Is Form SFN17987?

This is a legal form that was released by the North Dakota Department of Health - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the North Dakota Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN17987 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Health.

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Download Form SFN17987 "Asbestos Notification of Demolition and Renovation" - North Dakota

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ASBESTOS NOTIFICATION OF DEMOLITION AND RENOVATION
North Dakota Department of Health
Division of Air Quality
SFN 17987 (03/17)
I. Type of Notification
THIS NOTICE MUST BE SUBMITTED 10 WORKING DAYS BEFORE BEGINNING THE ACTIVITY
Date:
Original
Revised
Cancelled
II. Type of Operation
III. Is Asbestos Present?
□ Demolition
□ Renovation □ Ordered Demolition
□ Emergency Renovation
Yes
No
IV. Dates of Asbestos Removal (MM-DD-YY)
V. Dates of Demolition or Renovation (MM-DD-YY)
Start:
Stop:
Start:
Stop:
VI. Facility Information (identify owner and operator, if applicable)
Owner Name
Owner Address
City
State
Zip Code
Contact Person
Email
Telephone Number
Operator (if different than owner)
Operator Address
City
State
Zip Code
Contact Person
Email
Telephone Number
VII. Facility Description (include building name, number and floor or room number)
Building Name
Building Address
City
State
Zip Code
County
Site Location (floor or room number(s))
Building Size (Sq. Ft.)
Number of Floors
Age of Building/Year Built
Present Use
Prior Use
VIII. Asbestos Contractor (If applicable, please enter Demolition or Renovation Contractor information on page 2)
Contractor Name
ND License Number
Contractor Address
City
State
Zip Code
Contact Person
Telephone Number
IX. Asbestos Inspector
Firm Name
ND License Number
Firm Address
City
State
Zip Code
Name of Inspector
Telephone Number
X. Approximate Amount of Asbestos, Including:
Regulated Asbestos-
Nonfriable Asbestos-Containing Material
Nonfriable Asbestos-Containing Material
Containing Material
to be Removed
not to be Removed
(RACM)
Category I
Category II
Category I
Category II
to be Removed
Pipe (Linear Ft.)
Surface Area (Sq. Ft.)
Volume from Facility
Component(s)
(Cu. Ft.)
ASBESTOS NOTIFICATION OF DEMOLITION AND RENOVATION
North Dakota Department of Health
Division of Air Quality
SFN 17987 (03/17)
I. Type of Notification
THIS NOTICE MUST BE SUBMITTED 10 WORKING DAYS BEFORE BEGINNING THE ACTIVITY
Date:
Original
Revised
Cancelled
II. Type of Operation
III. Is Asbestos Present?
□ Demolition
□ Renovation □ Ordered Demolition
□ Emergency Renovation
Yes
No
IV. Dates of Asbestos Removal (MM-DD-YY)
V. Dates of Demolition or Renovation (MM-DD-YY)
Start:
Stop:
Start:
Stop:
VI. Facility Information (identify owner and operator, if applicable)
Owner Name
Owner Address
City
State
Zip Code
Contact Person
Email
Telephone Number
Operator (if different than owner)
Operator Address
City
State
Zip Code
Contact Person
Email
Telephone Number
VII. Facility Description (include building name, number and floor or room number)
Building Name
Building Address
City
State
Zip Code
County
Site Location (floor or room number(s))
Building Size (Sq. Ft.)
Number of Floors
Age of Building/Year Built
Present Use
Prior Use
VIII. Asbestos Contractor (If applicable, please enter Demolition or Renovation Contractor information on page 2)
Contractor Name
ND License Number
Contractor Address
City
State
Zip Code
Contact Person
Telephone Number
IX. Asbestos Inspector
Firm Name
ND License Number
Firm Address
City
State
Zip Code
Name of Inspector
Telephone Number
X. Approximate Amount of Asbestos, Including:
Regulated Asbestos-
Nonfriable Asbestos-Containing Material
Nonfriable Asbestos-Containing Material
Containing Material
to be Removed
not to be Removed
(RACM)
Category I
Category II
Category I
Category II
to be Removed
Pipe (Linear Ft.)
Surface Area (Sq. Ft.)
Volume from Facility
Component(s)
(Cu. Ft.)
SFN 17987 (03/17) Page 2
XI. Testing Procedure for Determining Asbestos and Type of Asbestos Material(s)
Type of Asbestos-Containing Material(s)
PLM
TEM
Other:
XII. Description of Work Practices and Engineering Controls to Prevent Asbestos Emissions (check all that apply)
Adequately Wet Materials
Glove Bag
Seal in Leaktight Containers
Encapsulate
Negative Air Containment
Seal in Leaktight Wrapping
Mini-enclosure
Other:
XIII. Description of Planned Demolition or Renovation Work (backhoe, bulldozer, hand removal, etc.)
Will the Facility or Facility Debris be Burned?
Yes
No If yes, you must contact your local Health Unit or the Air Quality Division at 701.328.5188, to complete an Open Burn Variance Application: SFN 8509.
XIV. Demolition Contractor
Firm Name
Secretary of State License Number
Firm Address
City
State
Zip Code
Contact Person
Telephone Number
XV. Waste Transporter
Name
Waste Hauler Permit Number
Address
City
State
Zip Code
Contact Person
Telephone Number
XVI. Waste Disposal Site for Asbestos-Containing Materials
Name
Permit Number
Telephone Number
Address
City
State
Zip Code
□ Yes
□ No
Will the waste be disposed of at a site other than a Landfill approved for asbestos?
If yes, you must contact the Waste Management Division at 701.328.5166 to complete an Inert Waste Disposal Variance Application: SFN 50278.
XVII. Waste Disposal Site for Demolition or Renovation Materials (other than asbestos)
Name
Permit Number
Telephone Number
Address
City
State
Zip Code
XVIII. If Demolition was Ordered by Government Agency, Identify the Agency and Attach a Copy of the Order
Authority/Agency
Date of Order (MM/DD/YY)
Telephone Number
XIX. Emergency Demolition or Renovation
Is this an emergency demolition or renovation?
Yes
No
If yes, you must contact the Department at 701.328.5188.
XX. Description of Procedures to be Followed in the Event of an Unexpected Asbestos Fiber Release
XXI. General Comments
XXII. I certify to the best of my knowledge that the above information is true and correct. I further certify that all asbestos abatement work on this project
will be performed by individuals certified in accordance with the North Dakota Air Pollution Control Rules 33-15-13.
Signature of Owner/Operator
Print Name
Date
Business/Organization
Telephone Number
Return form to:
North Dakota Department of Health
nd
Division of Air Quality, 2
Floor
918 E Divide Avenue
Bismarck, ND 58501-1947
Telephone:
701.328.5188 or
Fax: 701.328.5185 (If faxing, original copy must be mailed with valid signature)
SFN 17987 (12/16) Page 3
INSTRUCTIONS FOR COMPLETING THE
ASBESTOS DEMOLITION AND RENOVATION NOTIFICATION FORM
GENERAL INFORMATION
The Asbestos NESHAP, Section 33-15-13-02 of the North Dakota Air Pollution Control Rules, requires written notification of demolition or renovation
activities in facilities under Subsection 02.6. In most cases, a facility includes all types of structures except single family homes and apartment
buildings having no more than four units. The enclosed form must be used to fulfill this requirement. Only complete notification forms will be
accepted.
The notification should be typewritten or neatly printed and postmarked or delivered no later than ten working days prior to the beginning of either
the asbestos removal activity (Section IV) or demolition activity (in Section V) whichever is applicable.
INSTRUCTIONS
I.
Type of Notification: Check "Original" if the notification is a first time or original notification," Revised" if the notification is a revision of a
prior notification, or "Canceled" if the activity has been canceled. On the right side enter the date that the notification is being submitted.
II.
Type of Operation:
Check as appropriate for facility demolition, for facility renovation, for ordered demolitions, or for emergency
renovations.
III.
Is Asbestos Present? Answer "Yes" or "No."
IV.
Scheduled Dates of Asbestos Removal (MM-DD-YY): Enter scheduled dates (month/day/year) for asbestos removal work. Asbestos
removal work includes any activity, including site preparation, which may break up, dislodge or disturb asbestos material.
V.
Scheduled Dates of Demolition/Renovation (MM-DD-YY): Enter scheduled dates (month/day/year) for beginning and ending the planned
demolition or renovation project.
VI.
Facility Information: Enter the names, addresses, contact persons and telephone numbers of the following:
Owner: Legal owner of the site at which asbestos is being removed or demolition planned.
Operator: Demolition contractor, general contractor, or any other person who leases, operates, controls or supervises the site.
If known, the name of the site supervisor should be entered as the contact person for the notification. If additional parties share
responsibility for the site, demolition activity, renovation or ACM removal, include complete information (including name, address, contact
person and telephone number) on additional sheets submitted with the form.
VII.
Facility Description: Provide the following information on the areas being renovated or demolished:
Building Address:
Physical location of site.
Building Size:
The building size in square feet.
Number of Floors:
Enter the number of floors including basement, if applicable.
Year Facility was Built or Age:
Enter approximate age of the facility.
Present Use/Prior Use: Describe the primary use of the facility or enter the following codes: H -- Hospital; S -- School; P -- Public
Building; O -- Office; I -- Industrial; U -- University or College; C -- Commercial; or R -- Residence.
VIII.
Asbestos Contractor: Name and address of contractor hired to remove asbestos.
IX.
Asbestos Inspector: The firm who conducted the asbestos inspection prior to demolition/renovation.
SFN 17987 (12/16) Page 4
X.
Approximate Amount of Asbestos Including: (1) Regulated ACM to be removed (including nonfriable ACM to be sanded, ground or
abraded); (2) Category I and Category II nonfriable asbestos containing material (ACM) to be removed; and (3) Category I and
Category II nonfriable asbestos containing material not to be removed. For both renovations and demolitions, enter the amount of
RACM to be removed by entering a number in the appropriate box. If applicable, enter the amount of nonfriable ACM to be removed
during a demolition or renovation, and/or enter the amount of nonfriable ACM not to be removed during a demolition or renovation.
Category I nonfriable material includes packing, gaskets, resilient floor covering and asphalt roofing materials. Category II nonfriable
material includes any material, excluding Category I materials, that when dry, cannot be crumbled, pulverized or reduced to powder by
hand pressure, or mechanical forces expected to operate on the material during the demolition or renovation activity. All Category II
materials must be removed prior to demolition.
Complete the volume from facility component(s) if asbestos-containing materials have been removed from facility components and the
volume is known.
XI.
Asbestos Testing Procedure and Type of Asbestos Materials Present: Check the appropriate box for the procedure that was used to
determine asbestos content. Also, describe the kinds of asbestos-containing materials that are present.
XII.
Description of Work Practices and Engineering Controls to Prevent Asbestos Emissions: Check the appropriate box(s) for work
practices that will be employed to prevent asbestos emissions.
XIII.
Description of Planned Demolition or Renovation Work: Include a brief description of the renovation/demolition technique(s) to be
used. Also, indicate if the facility or facility debris will be burned.
XIII.
Demolition or Renovation Contractor: Name and address of contractor hired to perform demolition or renovation work.
XV.
Waste Transporter(s): Enter the name(s), addresses(s), contact person(s) and telephone number(s) of the person(s) or company(ies)
responsible for transporting ACM from the removal site to the waste disposal site. If the removal contractor or owner is the waste
transporter, state "same as owner" or "same as removal contractor." If multiple parties are responsible include complete information
on an additional sheet and submit with this form.
XVI.
Waste Disposal Site for the Asbestos-Containing Materials: Identify the waste disposal site, including the complete name, location,
and telephone number of the facility. If ACM is to be disposed of at more than one site, provide complete information on an additional
sheet submitted with the form. Permit number(s) must be included. If the waste will not be disposed of at a landfill approved for
asbestos, then an Inert Waste Disposal Variance Application must be completed and approved by the Department.
XVII.
Waste Disposal Site for Demolition or Renovation Materials: Identify the waste disposal site, including the complete name, location,
and telephone number of the facility. If the waste will not be disposed of at a landfill approved for waste materials, then an Inert Waste
Disposal Variance Application must be completed and approved by the Department.
XVIII.
If Demolition Ordered by a Government Agency, Please Identify the Agency below: Provide the name of the responsible official, title
and agency, authority under which the order was issued and the date of the order. A copy of the order from the government agency
must be attached to this form.
XIX.
Emergency Demolition or Renovation Information: Please identify if the work is an emergency demolition or renovation. If yes, please
immediately contact the Department.
XX.
Description of Procedures to be Followed in the Event that Unexpected Asbestos Fiber Release: Provide adequate information to
demonstrate that appropriate actions have been considered and can be implemented to control asbestos emissions adequately,
including at a minimum, conformance with applicable work practice standards. Attach an additional sheet of paper if needed and
submit with this form.
XXI.
General Comments: as necessary. Attach an additional sheet of paper if needed and submit with this form.
XXII.
Verification and Certification: Certify the accuracy and completeness of the information provided and the intent to comply with the
North Dakota Air Pollution Control Rules by signing and dating the notification form. Please sign and print the name of the owner or
operator and list the business or organization the owner or operator is affiliated with.
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