State Of Mississippi Demolition/renovation Notification Form (Page 2 of 2) in pdf

STATE OF MISSISSIPPI DEMOLITION/RENOVATION FORM - CONTINUED

XIV. WASTE ASBESTOS DISPOSAL SITE:

Name: ______________________________________________________________

Physical Location: ______________________________________________________________________________________________

Full Mailing Address: ___________________________________________________________________________________________

Contact Person: _____________________________________Telephone: ________________________________________________

* All asbestos waste should go to a permitted sanitary landfill.

XV.

DISPOSAL SITE FOR DEMOLITION DEBRIS (Other than asbestos):

Name: ________________________________________________________________________________________________________

Physical Location: ______________________________________________________________________________________________

Full Mailing Address:____________________________________________________________________________________________

Contact Person: _____________________________________ Telephone: ________________________________________________

All demolition debris (other than asbestos) should go to an authorized Rubbish Site, or to a permitted sanitary landfill.

XVI. REMOVAL/DEMOLITION PROCEDURES TO BE USED (Check all that apply):

____Strip & Removal

____Double Bagging

____Mechanical Chipping ____Component Removal

____Wrecking Ball

____Gross Demolition

____Remove Intact

____Bulldozer

____Containment

____Glove Bag

____Explode

____Negative Air

____Wet Method

____Roofing Saw

____Other - Explain Below:

XVII. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK:

___________________________________________________________________________________________

_________________________________________________________________________________

XVIII. PROCEDURES TO BE FOLLOWED IF UNEXPECTED ACM IS FOUND OR NONFRIABLE ACM

BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO A POWDER OR SMALL PIECES:

___________________________________________________________________________________________

__________________________________________________________________________________

*Will MDEQ be notified of any significant changes? ( ) yes ( ) no

XIX. IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, IDENTIFY THE AGENCY BELOW:

Name: ______________________________________________ Title: ___________________________________________________

Authority: _____________________________________________________________________________________________________

Date of Order: _____________________________

Date Demolition to Begin:

XX.

EMERGENCY DEMOLITION/RENOVATIONS:

Date of Emergency:

, Time:

Description of the sudden, unexpected event:

____________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Explanation of how the event caused unsafe conditions or would cause equipment damage or unreasonable financial burden:

__________________________________________________________________________________________

XXI.

When asbestos-containing material is present, an individual trained in the provisions of the regulation (40 CFR 61

Subpart M) will be on site during the demolition or renovation and evidence that the required training has been

accomplished by this person will be available for inspection during normal business hours.

I certify that all of the above information is correct.

___________________________________________

___________________________________

______________

Type or Print Name and Title

Signature

Date

MAIL TO:

Office of Pollution Control

101 West Capitol Street, Suite 100 OR

P.O. Box 10385

Jackson, MS 39201

Jackson, MS. 39289-0385

(601) 961-5171

State Of Mississippi Demolition/renovation Notification Form Page 2

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