Free Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program - Washington

Department of Labor and Industries Asbestos Certification Program PO Box 44614 Olympia WA 98504-4614

ASBESTOS ABATEMENT PROJECT NOTICE OF INTENT L&I DOSH ASBESTOS PROGRAM

This notice must be received no later than 10 calendar days prior to the start date. Complete all applicable boxes--incomplete or illegible notices will not be accepted. Circle changes on amended notices. Mail to the address above or fax to (360) 902-4409. Submit this form online or get more information at http://www.lni.wa.gov/TradesLicensing/LicensingReq/Asbestos/
Notice date: Start date: Completion: / / / / / / Initial On Hold Amended Off Hold Emergency Site Work Hours am to pm pm am Project Dates and Work Hours must be Exact Su Mo Tu We Th Fr Sa

CONTRACTOR
Company Name Contractor Certification Number Signature Printed Name Phone Number Job Site C.A.S. Name Owner's Agent Company Address City Phone number

PROPERTY OWNER

State

ZIP+4

JOB SITE
Address Building Name City ZIP + 4 County Room Type Age

FACILITY
Size

WA

Remodel Repair

Demolition Maintenance

QUANTITY OF ASBESTOS TO BE: Quantity ____________ square feet
Boiler insulation Duct paper VAT Roofing Other ______________ Fireproofing Popcorn ceiling CAB Sheet vinyl Asbestos paper

REMOVED

ENCAPSULATED Indoors Outdoors
Wrap & cut Wet methods HEPA vacuum Manual methods Other ______________

CONTROL MEASURES
Neg. pres. enclosure Glove bag Mini enclosure Critical barriers Other ______________

Quantity

____________

linear feet
Cement asbestos pipe Mudded pipe ins. Duct tape Other ______________

Mag. pipe insulation Air cell pipe insulation Ducting/duct insulation Other ______________

RESPIRATORY PROTECTION
½ mask APR Full face APR PAPR Type C continuous flow Type C pressure demand Other ______________ For clean copies go to http://www.lni.wa.gov/forms/

F413-025-000 notice of asbestos abatement project 9-2007