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DEMOLITION / RENOVATION NOTE: CIRCLE ITEMS THAT ARE AMENDED F NOTIFICATION FORM W TEXAS NOTIFICATION# O DepartmeM ot R Sto Hnhh Servioes 1) Abatement Contractor: DSHS License Number: p Address : City: State: Zip: F Office Phone Number: ( ) Job Site Phone Number.( 1 ~ Site Supervisor: DSHS License Number: ~ Site Supervisor: DSHS License Number: c Trained On-Site NESHAP Individual: Certification Date: f Demolition Contractor: Office Phone Number( ) u Address: City: State: Zip: S ~ 2) Project Consultant or Operator: DSHS License Number: Mailing Address: o City: State: Zip: Office Phone Number: ( ) N 3) Facility Owner: L Attention: Y Mailing Address: City: State: Zip: Owner Phone Number( ) T "Note: The invoice for the notifcation fee wiil be sent to the owner of the building at the address listed in this section after the _ project is completed. ti 4) Description or Facility Name: P Physical Address: County: City: Zip: A Facility Phone Number( ) Facility Contact Person: Description of Area/Room Number: 1_1 Prior Use: Future Use: N Age of Building/Facility: Size: Number of Floors: School (K -12): 1-1 YES ❑ NO 5 5) Type of Work (CHECK ONLY ONE): C Demolition o Renovation (Abatement) ❑ Annual Consolidated H Work will be during: 0 Day C Evening 0 Night 0 Phased Project A Description of work schedule: P 6) Type of Building (CHECK ONLY ONE): ❑ Public Building ❑ Federal Facility F-1, Industrial Site ❑ NESHAP-Only Facility 0 Is Building/Facility Occupied? ❑ YES l! NO T 7) Notification Type (CHECK ONLY ONE): ~ ❑ Original (10 Working Days) o Amendment ❑ Cancellation ❑ Emergency 0 Ordered (see item 15) H If this is an amendment, which amendment number is this?_ (Enclose copy of original andlor last amendment) If an emergency, who did you talk with at DSHS? Emergency#: ~ Date and Hour of Emergency (HH/MM/DD/YY): L Description of the sudden, unexpected event and explanation of how the event caused unsafe conditions or would cause V equipment damage (computers, machinery, etc O L 8) Description of procedures to be followed in the event that unexpected asbestos is found or previously non-friable A asbestos material becomes crumbled, pulverized, or reduced to powder: T I 0 9) Was an Asbestos survey performed? t:i YES r..l NO Date: DSHS Inspector License No: N Analytical Method: 0 PLM ❑ TEM D Assumed DSHS Laboratory License No: ~ (For TAHPA (Public buildin9) ProJects: an assumP tion must be made bY a DSHS Licensed InsPector) 0 Y 10) Description of planned demolition or renovation work, type of material, and method(s) to be used: E S 0 11) Description of work practices and engineering controls to be used to prevent emissions of asbestos at the N demolition/renovation: O 0UU2iJ