State Of Mississippi Demolition/renovation Notification Form
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2STATE OF MISSISSIPPI DEMOLITION/RENOVATION NOTIFICATION FORM
Please type or print legibly.
Incomplete notices will not meet notification requirements.
Revised: 2/00
I.
TYPE OF NOTICE:
( ) Original
( ) Revision
( ) Canceled
( ) Annual
( ) Info. Only
II.
TYPE OF PROJECT:
( ) Renovation
( ) Demolition
( ) Ordered Demolition
( ) Emergency Renovation
III.
SITE INFORMATION:
Name: _____________________________________________________________________________
Description: ___________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________
City: ___________________________ County: _______________
State: _______________ Zip: _________________________
Contact Person: ________________________________________ Telephone: _____________________________________________
IV.
OWNER INFORMATION:
Name: __________________________________________________________________________
Full Mailing Address: ___________________________________________________________________________________________
Contact Person: ___________________________________
Telephone: ________________________________________________
V.
ASBESTOS REMOVAL CONTRACTOR:
Name: __________________________________________________________
Certification No.: _________________________________________
Exp. Date: _________________________________________
Full Mailing Address: ___________________________________________________________________________________________
Contact Person:___________________________________
Telephone: ________________________________________________
VI.
CONTRACTOR (Other):
Name: _____________________________________________________________________________
Full Mailing Address: ___________________________________________________________________________________________
Contact Person: ___________________________________
Telephone: _______________________________________________
VII. ASBESTOS REMOVAL PROJECT DATES (MM/DD/YY):
Removal Project Start:
/
/
Removal Project Stop:
/
/
VIII. DEMOLITION/RENOVATION PROJECT DATES (MM/DD/YY):
Project Start:
/
/
Project Stop:
/
/
Prep. Date:
/
/
IX.
BUILDING INFORMATION:
Bldg. Size (SQ FT): ______________ Bldg. Size (LN FT): ______________________________
No. of Floors ________________ Age in Years: ______________________________________
______________________________________
Present Use: ________________________________________ Prior Use:
X.
ASBESTOS INSPECTION:
Was site inspected to determine presence of asbestos? ( ) yes ( ) no
Inspection Date:
/
/
Asbestos Present? ( ) yes ( ) no
Inspector:
Cert. No.: ______________________ Exp. Date: _____________________
Identify suspect materials sampled:_________________________________________________________________________________
Laboratory Analysis: TEM __________
PLM __________
Other _________________________________________________
Name of Laboratory: ____________________________________________________________________________________________
XI.
QUANTITY OF RACM TO BE REMOVED:
Pipes (LN FT) __________________ Surface Area (SQ FT) ___________________
Volume of Facility Components (CU FT) ___________________________________________________________________________
XII.
QUANTITY OF NONFRIABLE ASBESTOS - ________ NOT REMOVED ________ TO BE REMOVED:
/
Category I:
/
Category II:
XIII. WASTE TRANSPORTER:
Name: __________________________________________________________________________
Full Mailing Address: ___________________________________________________________________________________________
Contact Person: ___________________________________
Telephone: _____________________________________________
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