asbestos notification
TRANSCRIPT
8/20/2019 Asbestos Notification
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•*
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ASBESTOS/DEMOLITION NOTIFICATION FORM
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/ ~ O T I F I C A TION:
Select one and ill in the requested information) , fl. ,
[gl
ORIGINAL o
AMENDMENT
No._D cANCELLATION
( t f T £ ~
C0 AUG 2
4
20\5/<::YV
'NCY
as
emergency request made to the Regional Office or Environmental Health Notifications Group (EHNG) by phone?
DYes 0No
•If yes,
the DSHS reference : nd name
of
the Regional or
EHNG
representative with
whom
you spoke?
Date: I I
Time : __
Oa.m. Op.m.
•Describe the reason for Emergency:
0 ORDERED:
For structurally unsound acilities, attach copy
of
demolition order and identify Governmental Official)
Name: Registration No.
(x)
Below if
mended
Title:
Date
of
order (MM/DD/YY): I I Date order to begin (MM/DD/YY): I I
AMENDMENTS: You must complete the entire form and mark the appropriate check box es) along the /eft-hand side
of
his form to
indicate amended information.
3
TYPE
OF
WORK
[gj Asbestos Abatement D Demolition 0 Annual Consolidated
O&M
0 Abatement/Demolition
Is
this a phased project? 0
Yes
[gj No
FACILITY INFORMATION
' c e ; ~ e c
4ll ;
21
l fS
Nou eau.
lns/Jecqo Group
0 JIIit
. Facility Location
0
.......
Description or Facility Name: Former Theater
D .......
Physical Address: 1825 Abrams Rd.
D
....... County: Dallas City: Dallas Zip: 75214
0
.......
Facility Contact: Meg Robinson Phone : 972.619.6604
2.
Type
of
Facility
Select one)
[gj Public 0 Federal 0 Industrial/Manufacturing 0 NESHAP-Only 0 Public School
K-12
3.
Facility Details
0 ...... Description of Area/Room Number: Throughout Facility
0
...... Age
of
Building: 50+ Size: 12,000 Number
of l o o r s : ~
0
......
Is
this building occupied? 0
Yes
[gj No
0 ......
Prior
Use:
Theater
0 ......
Future
Use:
unknown
D
......
Date
of
Asbestos Survey/NESHAP Inspection: 7/16/14
D
...... DSHS
Inspector License : 60-0160
0
......
Analytical Method: [gj PLM 0
TEM
0 Assumed Asbestos 0 No Suspect Material
0.. . . . . DSHS
Laboratory License
:
30-0084
WORK SCHEDULE/ASBESTOS AMOUNTS Note:
i
he start
date(s)
entered below cannot be
met,
the DSHS Regional or Local
Program
office.J JM f.
be notified prior to the scheduled start
date.
Failure to
do
so is a violation
of TAHPA
Section 295.61.)
ent Work Schedule:
nd End date: 10/2/15
0
...... W o r k ~ a y s :
[gjMop/ [gjTues. [gjWed. [gjThurs. [gjFri. 0Sat.
Osun.
D ...... W o r k 1 ~ : Q Q [gj a.m. 0 p.m. to 4:00
Oa.m.
[glp.m.
2. Demolition Work Schedule:
0
......
Start date: 00/NA/00 and End date: 00/NA/00
D ...... Work
days:
0Mon. 0Tues. OWed. 0Thurs. 0Fri. Osat. Osun.
0 ......
Working hours:
00
[gj a.m. 0 p.m.
to 00
Oa.m.
[glp.m.
FORM
APB
5, REV 5/07
8/20/2019 Asbestos Notification
http://slidepdf.com/reader/full/asbestos-notification 2/4
x)
Belo'Y i f
Amended
.
C. ASBESTOS AMOUNTS
0 ...... Is Asbestos Present?
1:8]
Yes 0 No
Complete the table below
i
asbestos is present)
Asbestos-Containing Building Material Type
Approximate amount
of
Asbestos
*Only m rk the boxes below on this chart
i
hey are being amended
Pipes Ln Ln Surface Area SQ SQ
Cu
Ft M
Ft
M
Ft
0RACM to be removed
0
1]
13,400
1:8]
0
' :;
0RACM
left
in
place during demolition
0
[ J
0 0
. ; ~ ;
0Interior
Category I non-friable removed
0 0
1800
1:8]
0
0Exterior
Category I non-friable removed
[]
[ J
0 0
.
0Category_I
non-friable left in place during demolition
0 0 0 0
0Interior Category II non-friable removed
[]
[ J
0 0
.
0Exterior
Category II non-friable removed
0
0
0 0
..
·
0Category II non-friable left in place during demolition
0
[ J
0 0
< ..
0RACM Off-Facility Component
·
.
v:
DESCRIPTION
OF
WORK PRACTICES AND PROCEDURES
0 1. Description
of
procedures to be followed in the event that unexpected asbestos is found or previously non-friable asbestos
material becomes crumbled, pulverized, or reduced
to
powder: stop work, isolate area, clean with hepa vacuum and wet
wipe, and notify authorities.
0 2. DescriQtion
of
planned demolition or abatement work, type
of
material, and method(s): Plaster texture, duct insulation
mastic, Tire doors and flooring materials, will be bagged and disposed
of
as
ACJ\11
m a regulated landfill. Full
contamment and with wet decon, and negative pressure will be regmred. Workers will wear full PPE.
0 3. Description
of
work practices and engineering controls to be used to prevent emissions
of
asbestos at the demolition site:
ApSiicable containments, negative r.ressuret wet removal
of
materials, double bagged waste for transport to approved
Jan
hll. Waste transported m leak Igfit con amers.
PROJECT INFORMATION
0
... ...
A. FACILITY OWNER
Facility Owner Name: W.
W.
Willingham III, Trustee,
Gartner
720, Ltd., K & B La Vista Texas, Ltd., K&B Collins
Texas, Ltd., K&B Josey Texas, Ltd. (as tenants-in-common, not a partnership)
Phone : 469-688-8919
Attention: Doug Willingham
Mailing Address: 8525 Ferndale Rd., 204
City: DallasState: Texas Zip: 75238
0
......
B.
ASBESTOS ABATEMENT CONTRACTOR
1
DSHS Asbestos Contractor License : 80-0791
Contractor
Name:
1 Priority Environmental Services, Inc.
Address: 2573 Gravel
Dr
City:
Fort
Worth State: Texas Zip: 76118
Office Phone : (817) 595-0790 Job-Site Phone : (817) 913-6337
0 ...... C. ASBESTOS ABATEMENT CONTRACTOR 2
Only
i
here
is
more than one Contractor)
DSHS
Asbestos Contractor License
:
Contractor Name:
Address:
City: State: Zip:
Office Phone : ( ) - Job-Site Phone : ( ) -
D. ASBESTOS SUPERVISOR
0 ...... DSHS Supervisor License : 80-3805 Site Supervisor: Carlos Martinez
0 ......
DSHS
Supervisor License
:
80-2551 Site Supervisor: Felix Gonzalez
0 ......
DSHS
Supervisor License : per supervisor Site Supervisor: Any licensed supervisor
FORM APB 5,
REV
5/07
8/20/2019 Asbestos Notification
http://slidepdf.com/reader/full/asbestos-notification 3/4
I
1)
Below
if
Amended
E. NESHAP TRAINED
INDIVIDUAL
0 NESHAP Trained Individual: Carlos Martinez Certification Date: 04/21/14
0 NESHAP Trained Individual: Felix Gonzalez Certification Date: 03/10/14
0 NESHAP Trained Individual: Any
trained supervisor
Certification Date: per supervisor
0 F. DEMOLITION
CONTRACTOR
Demolition Contractor: NA
Address: NA
City:
NA
State: NA Zip: NA Phone : (214) 000-0000
0 G. PROJECT CONSULTANT
OR
OPERATOR
DSHS License No.: 10-0395
Project Consultant or Operator: Primera
Address: 835 E. Lamar Blvd 274
City: Arl ington State: Texas Zip: 76011 Phone : (817) 907-5993
0 ......
H.
Waste Transporter
DSHS Waste Transporter License : 40-0327
Waste Transporter: B&B
Waste Transit,
Inc.
Address: 1916 Bridgestone Drive
City:
Corinth
State: Texas Zip: 76210
Contact Person: Amy DrewPhone
:
(214) 803-3184
DSHS Waste Transporter License : 40-0355
Waste Transporter: 1 Priority Environmental Services, inc.
Address: 2573 Gravel Dr.
City: Ft. Worth State: TX Zip: 76118
Contact Person: Heath Watson
Phone :
(817) 819-6199
0 ...... 1.
Waste
Disposal Site
TCEQ Permit : 10258
FORM
Waste Disposal Site:
DFW
Landfill
Address: 1600 S. Railroad St
City: Lewisville State: Texas Zip: 75067
Phone : (972) 315-5421
CERTIFICATION STATEMENT
I hereby declare that I have examined this notification and, to the best of my knowledge and belief, all information provided is
complete, true, and correct. I affirm that I am the owner, operator, or delegated agent and that I am responsible for the fee
associated with notification. I also understand that the owner, operator, or delegated agent is responsible for notification t
the ddoartwent.
(Sign'(ture
of
Owner, Operator or Delegated Agent)
Heath Watson, for
1 PES and
agent
for
owner
(Printed Name & Title)
E-mail Address: hwatson@go 1 priority.com Phone
:
{817) 595-0790
IMPORTANT INFORMATION
NOTIFICATION TIMELINESS REQUIREMENT:
Date: 8/17/15
Your Asbestos/Demolition Notification form must be postmarked no less than ten working days (not
calendar days) prior to the start
of
any asbestos abatement or demolition.
FILING FEE: An invoice will be mailed to the facility owner upon completion of the project.
CALL FOR ASSISTANCE:
FORM
TO:
(512) 834-6747
or(888)
778-9440 (toll free
in
Texas)
ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
PO BOX 143538
AUSTIN, TX 78714-3538