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12) ALL applicable items in the following table must be completed: IF NO ASBESTOS PRESENT CHECK HERE E <br />Asbestos-Containing Building Material <br />Approximate amount of <br />Asbestos <br />Check unit of ineasurement <br />Type <br />Pipes <br />Surface Area <br />Ln <br />Ft <br />Ln <br />M <br />SQ <br />Ft <br />SQ Cu Cu <br />M Ft M <br />RACM to be removed <br />RACM NOT removed <br />Interior Cate o I non-friable removed <br />Exterior Cate o I non-friable removed <br />Cate o I non-friable NOT removed <br />Interior Cate o II non-friable removed <br />Exterior Cate o II non=friable removed <br />Cate o II non-friable NOT removed <br />RACM Off-Facility Component <br />13) Waste Transporter Name: DSHS License Number: <br />Address: City: State: Zip: <br />Contact Person: Phone Number: ( <br />) <br />14) Waste Disposal Site Name: <br />Address: City: State: Zip: <br />Telephone: ( 1 TCEQ Permit Number: <br />15) <br />For structurally unsound facilities, attach a copy of demolition order and identify Governmental Official below: <br />Name: Registration No: <br />Title: <br />Date of order (MM/DD/YY) / / Date order to begin (MM/DD/YY) <br />16) Scheduled Dates of Asbestos Abatement (MM/DD/YY) Start: Complete: <br />17) Scheduled Dates Demolition/Renovation (MM/DD/YY) Start: Complete: I I <br />Note: If the start date on this notification can not be met, the DSHS Regional or Local Program office Musf be contacted by <br />phone prior to the start date. Failure to do so is a violation in accordance to TAHPA, Section 295.61. <br />I hereby certify that all information I have provided is correct, complete, and true to the best of my knowledge. I acknowledge <br />that I am responsible for all aspects of the notification form, including, but not limiting, content and submission dates. The <br />maximum penalty is $10,000 per day per violation. <br />(Signature of Building OwneN Operator (Printed Name) (Date) (Telephone) <br />or Delegated Consultant/Contractor) <br />( 1 <br />MAIL TO: ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP (Fax Number) <br />DEPARTMENT OF STATE HEALTH SERVICES <br />*Faxes are not accepted* PO BOX 143538 *Faxes are not accepted* <br />AUSTIN, TX 78714-3538 <br />PH: 512-834-6612, 1-888-778-9440 <br />Form APB#5, dated 05/01/05. For assistance in completing form, call 1-888-778-9440 <br />- 000216 <br />