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DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00041 (5/09) Page 1 of 4

STATE OF WISCONSIN Bureau of Environmental & Occupational Health DHS 159, Wis. Adm. Code

ASBESTOS PROJECT NOTIFICATION
Completion of this form is mandatory for regulated asbestos projects under ch. DHS 159, Wis. Adm. Code. This form may not be used to meet the notification requirements for the Department of Natural Resources, chs. NR 406, 410, and 447. Refer to page 2 and the instructions for help completing and submitting notification. Shaded areas are for Department use only. Company project No. PROPERTY INFORMATION Property type (check most accurate response) Commercial/Industrial/Business [ Owner-occupied Public (church, library, etc.) Rental ] Other: K-12 School Government University Residential/No. Units Facility/building name, if applicable Property contact person Name of owner Street or fire code address Location of project on premises ASBESTOS PROJECT TYPE Check all that apply Removal Structure will be: NOTICE TYPE Original Cancellation Revision, No. Revising: Schedule Type/amount of ACM Other: Sub-project No: Enclosure Occupied Encapsulation Vacant Repair Other (describe): (If occupied, complete and post an Asbestos Occupant Protection Plan, Form F-44016) City Submitted DHS No.

Telephone No. ( ) Telephone No. ( ) Zip -

Planned renovation project

Start date(mm/dd/yy): x End date:

PROJECT SCHEDULE Start date includes project set-up Abatement dates (mm/dd/yy) Work days (Check all that apply) Start date: Mon. End date: Tues. Wed. Thurs. Fri. Sat. Sun. Work hrs: to a.m. a.m. p.m. p.m.

PRE-PROJECT ASBESTOS INSPECTION Inspection date(s) (mm/dd/yy) to ABATEMENT CONTRACTOR INFORMATION Company name Address City

Inspector name

Inspector DHS certification No.

DHS Certification No. & Expiration Date

Contact person name State Zip -

Office Telephone No. ( ) Cellular Telephone No. ( ) Total Amount of Asbestos Linear Feet Square Feet

TYPE AND AMOUNT OF ASBESTOS See page 2 for guidance Location: Interior Exterior Friable - Submit notification for: < 260 linear feet < 160 square feet < 35 cubic feet Any amount of asbestos in residential buildings with fewer than 5 units Type: Pipes/ducts Surfacing Other friable ACM: Non-Friable - Submit notification for asbestos projects involving: Flooring: Any amount, intact manual methods, or, <160 square feet, mechanical chipping Roofing: Any amount, intact manual methods, or, <5,580 square feet, power-sawing Siding: Any amount, intact methods only Other non-friable ACM: FEES See Page 2 for payment methods, See Instructions Page 2 for more on fees No fee required Original notice, 2 or more working days Sub-project Revision, less than 2 working days Original notice, less than 2 working days Planned renovation project notice

Cubic Feet Fee $50 $100 Received

PROJECT NOTIFICATION AFFIDAVIT -- I am an authorized representative of the abatement company named above. I certify that the information provided on this form is correct to the best of my knowledge and that this project complies with Ch. DHS 159, Wis. Adm. Code.

SIGNATURE ­ Authorized Representative

DHS certification number

Date Signed

F-00041 (5/09) Page 2 of 4

NOTIFICATION GUIDANCE ­ Follow these instructions to determine if asbestos project notification to DHS is required:
1. 2. 3. 4. Choose the table below that matches the property type. In that table, choose the row that describes the type of activity and amount of ACM involved in the activity. In that row, choose the column that describes the type of material (friable or non-friable). The cell at the intersection of the chosen row and column indicates whether or not notice is required to the department. Abatement Activity Removal of more than 1 bag* of ACM and up to any amount of removal Enclosure, encapsulation or repair of more than 3 square ft or more than 3 linear ft of ACM Table 2: All other structures, including residential with 5 or more dwelling units** Abatement Activity Removal of more than 1 bag* of ACM but less than 160 square ft, less than 260 linear ft, or less than 35 cubic ft Removal of 160 square ft or more, 260 linear ft or more, or 35 cubic ft or more of ACM Enclosure, encapsulation or repair of more than 3 square ft or more than 3 linear ft of ACM Friable Asbestos Notify DHS No DHS notice required** Notify DHS Non-friable Asbestos Notify DHS Notify DHS No DHS notice required Friable Asbestos Notify DHS Notify DHS Non-friable Asbestos Notify DHS No DHS notice required

* `Bag' means a disposal bag or glove bag no larger than 60" x 60", properly filled and sealed. ** Notice to Department of Natural Resources may be required. Notice is required to DNR for removal of any amount of friable or non-friable ACM on DNR-regulated demolition projects and for friable asbestos or RACM in amounts more than 160 square feet, 260 linear feet, or 35 cubic feet for renovation projects in residential buildings with 5 or more dwelling units and in all other facilities. Contact the DNR at 608266-2060 for more information on DNR notification requirements.

SUBMITTING NOTIFICATION ­ Also see instructions for further information on notification requirements.
Notification delivery methods allowed based on timing of submittal Original - 2 or more Original - less than 2 Revision Planned Renovation working days* notice working days* notice Project Sub-project - less Sub-project -2 or more working days* than 2 working days* notice notice - Fax - Fax - Fax - Fax - Fax - Fax - Email attachment - Email attachment - Email attachment - Email attachment - Email attachment - Email attachment - Delivery service - Delivery service - Personal delivery - Delivery service - Delivery service - Delivery service - Personal delivery - Personal delivery - Personal delivery - Personal delivery - Personal delivery - Postal service - Postal service - Postal service * `Working day' means any day except Saturday, Sunday, or, state or federal holidays. For notification purposes a working day ends at 4 p.m. Cancellations: Submit asbestos project cancellation before the start date on the original or most recently revised notice for the project by one of the following means: fax, email attachment, or personal delivery as provided under Delivery Methods. Delivery methods: Use one of the following methods for delivery, as allowed, based on the information provided above: - Fax: submit notification form with credit card payment form to 608-266-9711 - Email: submit notification form with credit card payment form to [email protected] - Personal delivery: submit notification form and payment to street address - Delivery service with guaranteed delivery schedule: send notification form and payment to street address - U.S. postal service (must be postmarked 4 working days or more before project start): mail notification form and payment to mailing address Mailing Address Department of Health Services Asbestos and Lead Section, Room 137 PO Box 2659 Madison WI 53701-2659 Call (608) 261-6876 with questions. PAYMENT METHODS ­ Payment is required at the time notice is submitted. See Instructions Page 2 for information on determining fees. - For notification submitted by fax or email, fee is payable only by credit card (Visa or MasterCard only) using the credit card payment form. - For notification submitted by personal delivery, delivery service, or U.S. postal service, fee is payable by credit card, check, or money order. - Cash is not accepted. Street Address Department of Health Services Asbestos and Lead Section 1 West Wilson Street, Room 137 Madison WI 53703

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Public Health F-00041 (5/09) Instructions Page 3 of 4

Bureau of Environmental & Occupational Health DHS 159, Wis. Adm. Code Instructions for Completing Asbestos Project Notifications

Each section on the notification form must be completed. The form must be signed and dated by an authorized representative of the asbestos company conducting the project, or electronically signed and dated by the authorized representative. Company project number ­ Assign a unique project number. This project number must be included on any revised or cancelled notice. PROPERTY INFORMATION ­ Complete the information requested about the property where the project will be conducted. Provide information needed to locate the actual asbestos project worksite on the property. Enter for `Property Contact Person' the owner, owner representative, or property manager to be contacted regarding the project. Property Type. Check the box that most accurately describes the use of the portion of the property where the asbestos activity will be conducted. Commercial/Industrial/Business. Property used for money-making purposes such as retail, firms and corporate business offices, private healthcare facilities, wholesale and warehousing, manufacturing and production. Public. Property not otherwise described that is routinely used by the public, such as a church, library, private college, YMCA or other club, non-profit healthcare, community center, or community arts theater or facility. K-12 School. Public or private academic school for children in grades kindergarten through 12. Government/University. Building owned, managed or leased by a local, state or federal governing body or organization, or, a 2-year or 4-year public college or university. Residential. Single-family or multi-family dwelling, apartment, condominium, loft, dormitory or other facility where any person resides. Include the total number of dwelling units in the structure and check whether the property is owner-occupied or rental. Other. Any other type of building or structure, including facilities such as: water towers, bridges, tunnels, parking structures. ASBESTOS PROJECT TYPE ­ Check all boxes that apply. Removal. Activity that takes out any or all ACM or suspect ACM in or on a structure or takes out any or all structural components that contain or are covered with ACM or suspect ACM. Enclosure. Activity that creates an airtight, impermeable, permanent barrier over or around ACM. Encapsulation. Activity that treats ACM with a product specifically designed to surround or embed asbestos fibers in an adhesive matrix. Repair. Activity that returns damaged ACM to an undamaged condition or to an intact state. Other. Activity not covered by standard abatement activities, such as chemical or mechanical conversion. Occupancy: Check the box that best describes the occupancy status of the structure during the asbestos activity. Check `Occupied' if any part of the attached structure will be occupied by persons or furnishings. Check `Vacant' if the structure will be empty of both occupants and furnishings for the duration. Note: If the structure will remain occupied or furnished during the asbestos activity, an Occupant Protection Plan, Form F-44016 must be completed and posted in plain view outside each regulated area. NOTICE TYPE ­ Check appropriate box for original, cancellation, revision, planned renovation project or sub-project notice. Original. Provides first written notice for a project. Cancellation. Cancels a project already notified. Once cancelled, a notice can not be reactivated. If a project is re-scheduled after being cancelled, a new notice with fee is required. Revision. Changes information on a previously submitted project notice. Enter the number of the revision in the space provided, (the first revision is Revision No. 1). Check box or boxes to indicate what information is being revised, the schedule, type or amount of ACM, or other (please describe). Circle all changed information on the notice form. - For a later start date, submit before the start date on the original notice. - For an earlier start date, submit at least 2 working days before the revised start date. Revised notice submitted less than 2 working days before the new start date shall include a $50 fee. - For an earlier end date, submit as soon as known. - For a later end date, submit before the project end date on the previous notice. - A notice may not be revised after the project end date provided on the previous notice. A new original notice with fee must be submitted. Planned Renovation Project. Provides notice for a planned renovation project expected to include a series of asbestos abatement activities conducted within a given time period not to exceed one year. - Notice shall be submitted at least 2 working days before the start of the planned renovation project. - Provide the renovation project start and end dates, not to exceed 12 months in length. Sub-project number. Sub-projects under planned renovation project notices must be separately notified to the department and must reference the company project number for the planned renovation project notice. For each sub-project notice under a Planned Renovation Project notice, assign a sub-project number that sequentially numbers the sub-projects for the renovation project (with the first sub-project numbered 1). Submit separate notice for each new sub-project when the asbestos activity meets the requirements for notification to DHS under Ch. DHS 159.20 (1), Wis. Adm. Code, and as provided on the tables on Page 2 of the notice form. Note: Keep a copy of any notice you submit. Use the copy for any future revisions. Make sure copies are clear and legible.

F-00041 (5/09) Instructions Page 4 of 4 PROJECT SCHEDULE ­ Project dates include the date set up begins and ends when the regulated areas are removed or dismantled. Abatement dates. Enter the start date and the end date for the project or sub-project, including set up dates. Work days. Check the boxes for the days of the week workers will be on the job. Work hours. Enter the standard daily work hours for the project ­ daily start and stop times. Note: A revised notice must be submitted whenever a start or end date or standard work schedule changes. Accurate information is necessary to allow the department to conduct onsite inspections as work is being conducted. If no one is present on site when a department representative arrives, the contractor may be found in non-compliance with Ch. DHS 159, Wis. Adm. Code. PRE-PROJECT ASBESTOS INSPECTION - If the structure was inspected prior to the asbestos abatement project (required for all demolitions, renovations, planned renovation projects and schools), complete the information requested, including the date the inspection was completed, the inspector's name and department certification number. ABATEMENT CONTRACTOR INFORMATION - Enter all information requested in this section. The contact person should be an authorized representative of the company who is knowledgeable about the project. This person should be readily available to the department by telephone throughout the project. Note: The company certification number and expiration date are located on the company certificate mailed to the asbestos company after certification approval was granted. This number must be provided with all notices submitted to the department. TYPE AND AMOUNT OF ASBESTOS - Check location of abatement project, type of asbestos and amount of asbestos to be abated. Page 2 of the notice form provides guidance to determine when notice is required to DHS. You also need to determine if notice is required to DNR. This Asbestos Project Notification form is good only for notification to DHS. Check with DNR at 608-266-2060 for their notification requirements and forms. Interior / Exterior. Check one or both boxes to indicate the project location or locations. Friable / Non-Friable. Check one or both boxes to indicate the type(s) of ACM to be abated. Friable. - Check the box or boxes that describe the amount of ACM or that project is at a residential structure with fewer than 5 units - Check the box or boxes for the types of material - pipes/ducts, surfacing, or other friable ACM. - If `other' is checked, describe the material. Non-Friable. - Check the box or boxes for the types of materials -flooring, roofing, siding, or other non-friable ACM - If `flooring' or `roofing' is checked, also check whether manual or mechanical methods will be used. - If `other' is checked, describe the material. Amount of Asbestos. In column 2 enter the total amount of ACM to be abated in linear, square or cubic feet. Use cubic feet only if unable to describe amount in linear or square feet. Use the guidance tables on page 2 of the form to determine if notification is required to DHS. Notification may be required to DNR. Contact DNR at 608-266-2060 for information on DNR notification requirements. FEES - Determine the notification fee, if any. Check the `No fee required' box if the project does not require a fee (see `revised notice and `planned renovation project and sub-project notices' below for cases where no fee is required). Note: A `working day' means any day except Saturday, Sunday, or state or federal holidays. Notices submitted after 4:00 p.m. are considered submitted the next working day. Original notice: $50 for an original notice submitted 2 working days or more before the project start date. $100 for an original notice submitted less than 2 working days before the project start date. Revised notice: $50 when a revision to an earlier start date is submitted less than 2 working days before the new start date. No fee is required for any other revision. Planned Renovation Project and Sub-Project notices: $100 for a planned renovation project notice. $50 for a sub-project notice submitted less than 2 working days before the start date of the sub-project. No fee is required for a sub-project notice submitted 2 working days or more before the start date. Completing the fee section. - If no fee applies, check the `No fee required' box. - If a fee applies, check the box that best describes the notification: original, sub-project, revision or planned renovation. - Check the appropriate fee amount in the Fee Enclosed column. - attach the fee: credit card, check, or money order depending on the delivery method. See the notice form Page 2 for more on payments. PROJECT NOTIFICATION AFFIDAVIT ­ The notification form must be signed by an authorized company representative who can vouch for the accuracy of the information provided. REVISIONS - Whenever information for a project changes, submit a revised notice to the department on a copy of the original notice. To complete the revised notice, be sure the original project number is clearly identified; in the `Notice Type' section of the form check `Revision' and enter the number of the revision in sequential order; circle or otherwise highlight all revised information. Revised notices may be submitted by the following means: fax, email attachment, or personal delivery as provided on page 2 of the notification form. Any fee required for a revision shall be submitted with the revision.