Hawaii Administrative Rules › Title 11 - DEPARTMENT OF HEALTH › Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS › Chapter 501 - ASBESTOS REQUIREMENTS › 3 - Asbestos Notification of Demolition and Renovation June 1, 1998

Current through June, 2024
Postmark:
Received:
Notification #:
I. Type of notification:
O=original R=revised C=cancelled
II. Type of operation:
D=Demolition R=Renovation OD=Ordered Demolition ER=Emergency Renovation
III. Facility information
Owner name:
Address:
City:
State:
Zipcode:
Contact person:
Telephone #:
Removal contractor:
License #:
Address:
City:
State:
Zipcode:
Contact person:
Telephone #:
Other operator:
Address:
City:
State:
Zipcode:
Contact person:
Telephone #:
IV. Is asbestos present
							 (y/n):
Inspector's name: Certification #: State of
							 certification:
V. Facility description (Include
							 building number, floor and room number)
Building name:
Address:
City:
State:
Zipcode:
Site location:
Building size (sq. ft.):
# Floors:
Age:
Present use:
Prior use:
VI. Procedure used to detect the
							 presence of asbestos
Laboratory name: Analytical method
Figure 3. Page 2 of 3
Asbestos Notification of Demolition and Renovation
June 1, 1998
VII. Specify the nature of the
							 asbestos material (TSI, surfacing, VAT, miscellaneous):
Amount of asbestos, including: 1. RACM to
							 be removed 2. CAT I left in place, and 3. CAT II left in place
RACM to be removed
Nonfriable ACM not to be removed
Category I
Category II
Pipes (linear ft.)
Surfacing (square ft.)
Facility components (cu. ft.)
VIII. Scheduled asbestos abatement
							 dates
Start (mm/dd/yy): Finish (mm/dd/yy) Circle workdays and times:
							 weekdays: daytime nighttime weekends: daytime nighttime
IX. Scheduled renovation/demolition
							 dates
Start (mm/dd/yy): Finish (mm/dd/yy) Circle workdays and times:
							 weekdays: daytime nighttime weekends: daytime nighttime
X. Description of the planned
							 renovation/demolition work and methods to be used:
XI. Description of the work
							 practices and engineering controls to be used to prevent emissions of asbestos
							 from the work-site:
Project designer name: Certification #: State:
XII. Waste transporter #1
Name:
Address:
City:
State:
Zipcode:
Contact Person:
Telephone:
Waste transporter #2
Name:
Address:
City:
State:
Zipcode:
Contact Person:
Telephone:
Figure 3. Page 3 of 3 Asbestos Notification of Demolition
				  and Renovation
June 1, 1998
XIII. Waste disposal site:
Facility Name:
Telephone:
Address:
City:
State:
Zipcode:
XIV. For demolition ordered by a
							 government agency, please identify:
Name:
Title:
Authority (Agency):
Date of order (mm/dd/yy):
Date ordered to begin (mm/dd/yy):
XV. For emergency
							 renovations:
Date and time of emergency Date
							 (mm/dd/yy): Time: (a.m./p.m.)
Description of sudden, unexpected event
							 and the damage caused:
Explanation of how the event caused an
							 unsafe condition or would cause equipment damage or an unreasonable financial
							 burden:
Person contacted for approval at the
							 Noise, Radiation & Indoor Air Quality Branch: Name: Date (mm/dd/yy): Time:
							 (a.m./p.m.)
XVI. Description of procedures to be
							 followed in the event that unexpected asbestos is found or previously
							 nonfriable asbestos material becomes crumbled, pulverized or reduced to
							 powder:
XVII. 1 certify that an individual
							 trained in the provisions of Hawaii administrative rules chapter 11-501, and
							 certified as a contractor/supervisor, will be on-site during the entire
							 renovation and/or demolition and evidence that the required training has been
							 accomplished for this and all workers will be available at the
							 work-site.
______________________ ______________ Signature of
							 owner/operator Date (mm/dd/yy):
XVIII. I certify that the
							 information on this notification is correct.
______________________
							 ______________ Signature of owner/operator Date (mm/dd/yy):