GEORGIA PROJECT NOTIFICATION FORM
FOR ASBESTOS RENOVATION, ENCAPSULATION, OR DEMOLITION
USE AN ATTACHMENT TO PROVIDE ADDITIONAL INFORMATION FOR ANY SECTION WHEN NEEDED TO PROVIDE COMPLETE
DETAILS.
DO NOT LEAVE ANY SECTION BLANK – INSERT UNKNOWN OR N/A IF NEEDED.
FOR PROJECTS WHERE FEES ARE DUE:
EPD ASBESTOS FEES LOCKBOX
POST OFFICE BOX 101173
ATLANTA, GEORGIA 30392
(SEE SECTION 6 FOR FEE CALCULATION INSTRUCTIONS)
FOR PROJECTS WHERE FEES ARE NOT DUE:
EPD ASBESTOS PROGRAM
ATTN: ASBESTOS NOTIFICATIONS
4244 INTERNATIONAL PARKWAY, SUITE 104
ATLANTA, GEORGIA 30354
SECTION 1A - TYPE OF NOTICE (USE THE APPROPRIATE CHECKBOX TO INDICATE THE TYPE OF NOTICE YOU ARE SUBMITTING)
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ORIGINAL - INITIAL |
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REVISION #_______ |
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SECTION 1B - TYPE OF PROJECT |
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CHECK IF SECTION REVISED |
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RENOVATION/ABATEMENT ONLY |
RENOVATION/ABATEMENT PRIOR TO DEMOLITION |
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ENCAPSULATION |
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DEMOLITION ONLY |
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JOINT DEMOLITION/RENOVATION |
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ORDERED DEMOLITION |
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EMERGENCY |
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COURTESY (FOR NON-FRIABLE PROJECTS OR UNDER TRIGGER |
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QUANTITY PROJECTS ONLY!!!) |
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SECTION 2 – SITE INFORMATION |
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CHECK IF SECTION REVISED |
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PROJECT NAME: |
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PROJECT ADDRESS: |
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PROJECT CITY: |
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ZIP: |
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COUNTY: |
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NEAREST MAJOR INTERSECTION: |
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BLDG SIZE IN SQ. FT: |
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AGE OF BUILDING IN YEARS: |
NUMBER OF FLOORS IN BUILDING: |
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SPECIFIC LOCATION IN BUILDING OF ASBESTOS BEING REMOVED: |
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SECTION 3A – ABATEMENT CONTRACTOR |
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CHECK IF SECTION REVISED |
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ASBESTOS REMOVAL CONTRACTOR: |
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CONTRACTOR’S STREET ADDRESS: |
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COMPANY CERTIFICATE #: |
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CITY: |
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STATE: |
ZIP: |
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PHONE: |
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FAX: |
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GA LICENSED AGENT: |
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GA AGENT’S ID: |
EXPIRES: |
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CELL PHONE: |
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3B – DEMOLITION CONTRACTOR |
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CHECK IF SECTION REVISED |
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DEMOLITION CONTRACTOR: |
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DEMOLITION CONTRACTOR’S STREET ADDRESS:
SECTION 4 – ACM INFORMATION* Required for Compliance of Georgia Rules |
CHECK IF SECTION REVISED |
IS ASBESTOS PRESENT? YES |
NO UNKNOWN |
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FRIABLE |
NON-FRIABLE |
BOTH |
DID AN AHERA ACCREDITED INSPECTOR INSPECT THIS SITE? |
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YES |
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NO |
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ASSUMED ASBESTOS |
INSPECTOR NAME: |
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INSPECTOR PHONE: |
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ACCREDITATION COURSE: |
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CERTIFICATE NUMBER: |
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EXPIRES: |
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SECTION 5 – WORK SCHEDULES (10 WORKING DAY ADVANCE NOTIFICATION REQUIRED FOR NON-EMERGENCY NOTIFICATIONS!) |
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CHECK IF SECTION REVISED |
ABATEMENT START DATE |
ABATEMENT END DATE |
WORK DAYS (MON-SUN) |
WORK HOURS (EX : 7A – 4P) |
WORK HOURS (EX : 7A – 4P)
SECTION 6 – ACM AMOUNTS, TYPE CODES, AND FEE CALCULATION
CHECK IF SECTION REVISED
FIRST, LOCATE THE MATERIAL TO BE REMOVED IN COLUMN A. COLUMN B SHOWS THE USUAL NESHAP CATEGORY FOR THE
MATERIAL. COLUMN C SHOWS THE CATEGORY THE MATERIAL WILL LIKELY BECOME DURING ABATEMENT, AND THAT IS THE CODE THAT SHOULD BE USED FOR COMPLETING THIS FORM. NOW, ENTER THE SQ. FT AND/OR L.F. AMOUNTS OF ACM TO BE ABATED DURING THIS PROJECT UNDER THE CORRECT HEADING ACCORDING TO TYPE IN COLUMN D, E, AND/OR F. THEN, LOCATE THE CORRESPONDING TYPE CODE(S) FOR THE MATERIAL(S) IN COLUMN G AND ENTER THE CODES IN THE SPACES PROVIDED BEFORE PROCEEDING TO THE FEE CALCULATION SECTION.
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Column A |
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Column B |
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Column C |
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SF OR LF AMOUNT TO BE ABATED |
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Column |
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DURING PROJECT |
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G |
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USUAL NESHAP CATEGORY |
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WILL |
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LIKELY |
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Column D |
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Column E |
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Column F |
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ACM |
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ACM TYPE |
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Category |
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Category |
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BECOME |
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TYPE |
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RACM |
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Category I |
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Category 2 |
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RACM |
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1 |
2 |
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WHEN |
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CODE |
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ABATED |
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ASBESTOS ASPHALT SHINGLES |
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√ |
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1 OR RACM |
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AAS |
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ASBESTOS CEMENT (TRANSITE) PANELS |
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√ |
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√ |
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2 OR RACM |
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ACP |
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ASBESTOS CEMENT (TRANSITE) ROOFING |
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√ |
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√ |
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RACM |
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ACR |
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ASBESTOS CEMENT (TRANSITE) SIDING SHINGLES |
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√ |
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√ |
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RACM |
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ACS |
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ASBESTOS FLASHING |
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√ |
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√ |
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1 |
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AF |
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ASBESTOS GASKET |
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√ |
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√ |
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1 OR RACM |
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AG |
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BOILER INSULATION |
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√ |
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RACM |
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BI |
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BUILT-UP ROOFING |
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√ |
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1 OR RACM |
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BUR |
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COVE (BASEBOARD) MOLDING MASTIC |
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√ |
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1 |
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CM |
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CEILING PLASTER |
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√ |
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RACM |
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CP |
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CEILING TILE |
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√ |
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RACM |
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CT |
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DUCT SEAM MASTIC |
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√ |
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1 |
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DSM |
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DUCT VIBRATION DAMPENERS |
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√ |
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√ |
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1 OR RACM |
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DVD |
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EXTERIOR (OUTSIDE) DUCT INSULATION |
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√ |
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√ |
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RACM |
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EDI |
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FELT DUCT TAPE |
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√ |
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RACM |
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FDT |
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FLOOR MASTIC |
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√ |
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1 |
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FM |
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FIREPROOFING |
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√ |
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RACM |
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FP |
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FIREPROOFING AND OVERSPRAY |
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√ |
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RACM |
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FPO |
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FLOOR TILE |
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√ |
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1 OR RACM |
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FT |
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FLOOR TILE AND MASTIC |
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√ |
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1 OR RACM |
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FTM |
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INTERIOR (INSIDE) DUCT INSULATION |
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√ |
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√ |
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RACM |
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IDI |
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JOINT COMPOUND ONLY |
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√ |
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RACM |
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JC |
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LIGHT WEIGHT CONCRETE |
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√ |
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√ |
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RACM |
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LWC |
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OTHER: FLOOR LEVELING COMPOUND, CAULKING, |
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√ |
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√ |
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2 OR RACM |
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OTR |
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ETC. |
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PIPE INSULATION STRAIGHT RUNS |
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√ |
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RACM |
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PI |
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PIPE INSULATION ELBOWS AND FITTINGS |
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√ |
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RACM |
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PIE |
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RESILIENT FLOOR COVERINGS (SHEET FLOORING; |
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√ |
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√ |
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1 OR RACM |
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RFC |
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LINOLEUM) |
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ROOF MASTICS AND COATINGS |
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√ |
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√ |
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1 |
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RMC |
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ROOFING SILVER COATING |
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√ |
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1 OR RACM |
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RSC |
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TEXTURED CEILING |
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√ |
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RACM |
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TC |
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TEXTURED CEILING PLASTER |
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√ |
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RACM |
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TCP |
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TANK INSULATION |
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√ |
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RACM |
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TI |
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WALL BOARD AND JOINT COMPOUND |
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√ |
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RACM |
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WBJC |
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WINDOW GLAZING |
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√ |
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√ |
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1 OR RACM |
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WG |
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WALL PLASTER |
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√ |
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RACM |
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Row G: Enter the ACM Type Codes from Col. G for each Category Below. |
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Category 1 |
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Category 2 |
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RACM |
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Category 1: ____________________________________________________________________________ |
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Total |
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Total |
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Total |
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Category 2: ____________________________________________________________________________ |
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RACM: ________________________________________________________________________________ |
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CALCULATING FEES |
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Row H. IS THIS A RESIDENTIAL PROJECT |
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YES |
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(USE TOTAL FROM COLUMN F (RACM) TO COMPLETE THIS SECTION) |
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RESIDENTIAL FEE SCHEDULE: $0.10 PER LF/SF |
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RESIDENTIAL PROJECT |
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TOTAL FEES DUE AND PAYABLE NOW |
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OF FRIABLE ACM WITH MINIMUM FEE: $25 - |
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COLUMN F (RACM) TOTAL |
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X $0.10 |
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H (B) $_____________________ |
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MAXIMUM FEE: $50 PER RESIDENCE/ DWELLING |
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H (A). ___________SF/LF |
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EQUALS |
(NOT TO BE LESS THAN $25 OR MORE THAN $50 PER |
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UNIT. |
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UNIT) |
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Row I. IS THIS A NON-RESIDENTIAL PROJECT |
YES |
(USE TOTAL FROM COLUMN F (RACM) TO COMPLETE THIS SECTION) |
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NON-RESIDENTIAL FEE SCHEDULE: $0.10 PER
LF/SF OF FRIABLE ACM WITH MINIMUM FEE: $25 -
MAXIMUM FEE: $1,000 PER FACILITY.
NON-RESIDENTIAL PROJECT COLUMN F (RACM) TOTAL
I (A). ___________SF/LF
TOTAL FEES DUE AND PAYABLE NOW
I (B) $_____________________
(NOT TO BE LESS THAN $25 OR MORE THAN $1,000)
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CHECK NUMBER ____________ FOR THE AMOUNT SHOWN IN THE TOTAL FEES DUE ABOVE. |
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REV 062012005F |
- 2 - |
SECTION 7 - WASTE TRANSPORTER, DISPOSAL SITE, AND BUILDING OWNER INFORMATION
CHECK IF SECTION REVISED
WASTE TRANSPORTERTRANSPORTER CONTACT PERSON: NAME
TRANSPORTER’S MAILING ADDRESS:
CITY: |
STATE: |
ZIP: |
PHONE: |
FAX: |
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All Detached Non-Friable and Friable ACM Must Go To an ACM Permitted Landfill.
DISPOSAL SITE |
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DI SPOSAL SI TE COUNTY: |
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NAME: |
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DISPOSAL SITE ADDRESS: |
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CITY: |
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ZIP: |
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PHONE: |
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FAX: |
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PROJECT OWNER |
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OWNER’S REPRESENTATIVE: |
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NAME: |
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OWNER’S STREET ADDRESS: |
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OWNER’S MAILING ADDRESS (IF DIFFERENT): |
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CITY: |
STATE: |
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ZIP: |
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PHONE: |
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FAX: |
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SECTION 8 - WORK METHODS: METHOD OF DEMOLITION AND/OR RENOVATION ACTIVITY (DESCRIPTION OF WORK PRACTICES, |
ENGINEERING CONTROLS, AND CLEARANCE METHODS) |
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CHECK IF SECTION REVISED |
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SECTION 9 - ADDITIONAL PROJECT INFORMATION |
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CHECK IF SECTION REVISED |
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WILL ASBESTOS REMAIN IN THE PROJECT AREA? |
NO |
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YES |
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UNKNOWN |
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EXPLAIN ‘YES’ OR ‘UNKNOWN’: |
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IF NO ASBESTOS IS PRESENT, WAS THIS PROJECT PREVIOUSLY ABATED? |
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NO |
YES |
UNKNOWN |
PRIOR ABATEMENT COMPANY: |
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YEAR ABATED: |
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PRIOR COMPANY CONTACT PERSON: |
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PHONE: |
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CERTIFICATION OF INFORMATION AND ACKNOWLEDGEMENT
CHECK IF SECTION REVISED
I, THE UNDERSIGNED, CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF FEDERAL REGULATIONS (NESHAP/40 CFR PART 61 SUBPART M) WILL BE
ON THE PROJECT SITE DURING DEMOLITION AND/OR RENOVATION ACTIVITIES DESCRIBED IN THE NOTIFICATION. EVIDENCE THAT THIS PERSON AND ALL OTHER PROJECT PERSONNEL HAVE ACCOMPLISHED APPROPRIATE TRAINING AND TRAINING CERTIFICATES WILL BE AVAILABLE FOR INSPECTION DURING NORMAL BUSINESS HOURS AND ANYTIME REGULATED ACTIVITIES ARE BEING CONDUCTED ON SITE.
I FURTHERMORE UNDERSTAND THAT I AM RESPONSIBLE FOR THE ACCURACY AND COMPLETENESS OF THE INFORMATION SUBMITTED WITH THIS
NOTIFICATION AND I SHALL PROMPTLY SUBMIT REVISIONS, SUPPORTING DOCUMENTS, AND PROJECT FEES.
REPRESENTING: OWNER |
ABATEMENT CONTRACTOR DEMOLITION CONTRACTOR OTHER _________________ |
COMPANY NAME IF “OTHER” CHECKED:
ADDRESS IF “OTHER” CHECKED:
•REFER TO THE DETAILED INSTRUCTIONS WHEN IN DOUBT ABOUT PROPER COMPLETION OF ANY SECTION.
•NEVER LEAVE BLANK SPACES – INSERT ‘N/A’ OR ‘UNKNOWN’ FOR ANY BLANK WHERE YOU DO NOT HAVE THE INFORMATION REQUESTED.
•PRINT RESPONSES NEATLY AND LEGIBLY.
•ALWAYS KEEP A COPY OF THIS FORM FOR YOUR RECORDS, AND PROVIDE COPIES TO ALL OTHER INVOLVED PARTIES.
•EPD NO LONGER ACCEPTS ‘FAX ONLY DOCUMENTS’. SUBMIT THE ENTIRE FORM VIA MAIL.
•NEVER SUBMIT PROJECTS WHERE FEES ARE DUE WITHOUT ATTACHING THE REQUIRED FEE CHECK OR MONEY ORDER.
•NOTIFICATIONS WITH FEES MUST BE MAILED TO THE EPD ASBESTOS FEES POST OFFICE ADDRESS. NOTIFICATIONS WITHOUT FEES SHOULD BE MAILED DIRECTLY TO THE EPD OFFICE ADDRESS.
(ADDRESSES ARE ON THE FIRST PAGE.)
•DO NOT SUBMIT ‘TWO-SIDED’ PHOTO COPIES.
•If a Project Notification is submitted by someone other than the asbestos abatement or demolition contractor - such as the Consultant or Owner,
A REVISED NOTIFICATION MUST BE SUBMITTED BY THE CONTRACTOR TO WHOM THE PROJECT IS AWARDED BEFORE WORK BEGINS. THE CONTRACTOR MUST SIGN THE CERTIFICATION OF THE REVISED NOTIFICATION FORM.
IT IS YOUR RESPONSIBILITY TO SUBMIT THIS FORM ACCURATELY AND COMPLETLY AND INCLUDE BY ALL
APPLICABLE FEES.
SUMMARY INSTRUCTIONS FOR COMPLETING THE GEORGIA EPD
PROJECT NOTIFICATION FOR ASBESTOS RENOVATION, ENCAPSULATION, OR DEMOLITION PROJECTS
Complete the following Sections and provide the information requested according to the type of project being performed.
To Be Completed For Demolition Work (No fees due for Demolition Projects.)
Section 1AVType of Notice
Section 1BVType of Project
Section 2 - Site Information
Section 3B - Demolition Contractor
Section 4 - ACM Information Asbestos Inspection Required for Compliance of Georgia Rules.
Section 5 - Work Schedules for Demolition
Section 6 - ACM Amounts & Type Codes
All ACM which already is or will become friable must be removed before demolition; only non-friable ACM may be remaining during the demolition and it must ALL be collected, packaged, labeled, transported and disposed as ACM Waste).
If all ACMs have been removed from the project site, Page 2 is not required.
Section 7 - Waste Transporter and Disposal Site of Demolition Waste, and Building Owner (All Required) Section 8 - Work Methods
Section 9 - Additional Project Information
Certification of Information and Acknowledgement (No fees due for Demolition Projects.)
To Be Completed For Asbestos Removal and Encapsulation Projects (Fees due for Abatement Projects.)
Section 1A - Type of Notice
Section 1B - Type of Project
Section 2 - Site information
Section 3A - Abatement Contractor
Section 4 - ACM Information Asbestos Inspection Required for Compliance of Georgia Rules.
Section 5 - Work Schedules for Abatement and Encapsulation Projects.
Section 6 - ACM Amounts, Type Codes, and Fee Calculation
Section 7 - Waste Transporter, Disposal Site, and Building Owner Information
Section 8 - Work Methods
Certification of Information and Acknowledgment
To Be Completed for A Revision To A Prior Notification
Section 1A Type of Notice
Section(s) All Sections, In Which the Prior Information Has Changed or Needs To Be Updated.
Check the Revision Box In Each of The Revised Sections and Update the Information.
Certification of Information and Acknowledgment
DETAILED INSTRUCTIONS ARE AVAILABLE FOR FILLING OUT EACH OF THESE SECTIONS.