Asbestos Notification

8/20/2019 Asbestos Notification

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ASBESTOS/DEMOLITION NOTIFICATION FORM

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/ ~ O T I F I C A TION:

Select one and ill in the requested information) , fl. ,

[gl

ORIGINAL o

AMENDMENT

No._D cANCELLATION

( t f T £ ~

C0 AUG 2

4

20\5/<::YV

'NCY

as

emergency request made to the Regional Office or Environmental Health Notifications Group (EHNG) by phone?

DYes 0No

•If yes,

the DSHS reference : nd name

of

the Regional or

EHNG

representative with

whom

you spoke?

Date: I I

Time : __

Oa.m. Op.m.

•Describe the reason for Emergency:

0 ORDERED:

For structurally unsound acilities, attach copy

of

demolition order and identify Governmental Official)

Name: Registration No.

(x)

Below if

mended

Title:

Date

of

order (MM/DD/YY): I I Date order to begin (MM/DD/YY): I I

AMENDMENTS: You must complete the entire form and mark the appropriate check box es) along the /eft-hand side

of

his form to

indicate amended information.

3

TYPE

OF

WORK

[gj Asbestos Abatement D Demolition 0 Annual Consolidated

O&M

0 Abatement/Demolition

Is

this a phased project? 0

Yes

[gj No

FACILITY INFORMATION

' c e ; ~ e c

4ll ;

21

l fS

Nou eau.

lns/Jecqo Group

0 JIIit

. Facility Location

0

.......

Description or Facility Name: Former Theater

D .......

Physical Address: 1825 Abrams Rd.

D

....... County: Dallas City: Dallas Zip: 75214

0

.......

Facility Contact: Meg Robinson Phone : 972.619.6604

2.

Type

of

Facility

Select one)

[gj Public 0 Federal 0 Industrial/Manufacturing 0 NESHAP-Only 0 Public School

K-12

3.

Facility Details

0 ...... Description of Area/Room Number: Throughout Facility

0

...... Age

of

Building: 50+ Size: 12,000 Number

of l o o r s : ~

0

......

Is

this building occupied? 0

Yes

[gj No

0 ......

Prior

Use:

Theater

0 ......

Future

Use:

unknown

D

......

Date

of

Asbestos Survey/NESHAP Inspection: 7/16/14

D

...... DSHS

Inspector License : 60-0160

0

......

Analytical Method: [gj PLM 0

TEM

0 Assumed Asbestos 0 No Suspect Material

0.. . . . . DSHS

Laboratory License

:

30-0084

WORK SCHEDULE/ASBESTOS AMOUNTS Note:

i

he start

date(s)

entered below cannot be

met,

the DSHS Regional or Local

Program

office.J JM f.

be notified prior to the scheduled start

date.

Failure to

do

so is a violation

of TAHPA

Section 295.61.)

ent Work Schedule:

nd End date: 10/2/15

0

...... W o r k ~ a y s :

[gjMop/ [gjTues. [gjWed. [gjThurs. [gjFri. 0Sat.

Osun.

D ...... W o r k 1 ~ : Q Q [gj a.m. 0 p.m. to 4:00

Oa.m.

[glp.m.

2. Demolition Work Schedule:

0

......

Start date: 00/NA/00 and End date: 00/NA/00

D ...... Work

days:

0Mon. 0Tues. OWed. 0Thurs. 0Fri. Osat. Osun.

0 ......

Working hours:

00

[gj a.m. 0 p.m.

to 00

Oa.m.

[glp.m.

FORM

APB

5, REV 5/07



x)

Belo'Y i f

Amended

.

C. ASBESTOS AMOUNTS

0 ...... Is Asbestos Present?

1:8]

Yes 0 No

Complete the table below

i

asbestos is present)

Asbestos-Containing Building Material Type

Approximate amount

of

Asbestos

*Only m rk the boxes below on this chart

i

hey are being amended

Pipes Ln Ln Surface Area SQ SQ

Cu

Ft M

Ft

M

Ft

0RACM to be removed

0

1]

13,400

1:8]

0

' :;

0RACM

left

in

place during demolition

0

[ J

0 0

. ; ~ ;

0Interior

Category I non-friable removed

0 0

1800

1:8]

0

0Exterior

Category I non-friable removed

[]

[ J

0 0

.

0Category_I

non-friable left in place during demolition

0 0 0 0

0Interior Category II non-friable removed

[]

[ J

0 0

.

0Exterior

Category II non-friable removed

0

0

0 0

..

·

0Category II non-friable left in place during demolition

0

[ J

0 0

< ..

0RACM Off-Facility Component

·

.

v:

DESCRIPTION

OF

WORK PRACTICES AND PROCEDURES

0 1. Description

of

procedures to be followed in the event that unexpected asbestos is found or previously non-friable asbestos

material becomes crumbled, pulverized, or reduced

to

powder: stop work, isolate area, clean with hepa vacuum and wet

wipe, and notify authorities.

0 2. DescriQtion

of

planned demolition or abatement work, type

of

material, and method(s): Plaster texture, duct insulation

mastic, Tire doors and flooring materials, will be bagged and disposed

of

as

ACJ\11

m a regulated landfill. Full

contamment and with wet decon, and negative pressure will be regmred. Workers will wear full PPE.

0 3. Description

of

work practices and engineering controls to be used to prevent emissions

of

asbestos at the demolition site:

ApSiicable containments, negative r.ressuret wet removal

of

materials, double bagged waste for transport to approved

Jan

hll. Waste transported m leak Igfit con amers.

PROJECT INFORMATION

0

... ...

A. FACILITY OWNER

Facility Owner Name: W.

W.

Willingham III, Trustee,

Gartner

720, Ltd., K & B La Vista Texas, Ltd., K&B Collins

Texas, Ltd., K&B Josey Texas, Ltd. (as tenants-in-common, not a partnership)

Phone : 469-688-8919

Attention: Doug Willingham

Mailing Address: 8525 Ferndale Rd., 204

City: DallasState: Texas Zip: 75238

0

......

B.

ASBESTOS ABATEMENT CONTRACTOR

1

DSHS Asbestos Contractor License : 80-0791

Contractor

Name:

1 Priority Environmental Services, Inc.

Address: 2573 Gravel

Dr

City:

Fort

Worth State: Texas Zip: 76118

Office Phone : (817) 595-0790 Job-Site Phone : (817) 913-6337

0 ...... C. ASBESTOS ABATEMENT CONTRACTOR 2

Only

i

here

is

more than one Contractor)

DSHS

Asbestos Contractor License

:

Contractor Name:

Address:

City: State: Zip:

Office Phone : ( ) - Job-Site Phone : ( ) -

D. ASBESTOS SUPERVISOR

0 ...... DSHS Supervisor License : 80-3805 Site Supervisor: Carlos Martinez

0 ......

DSHS

Supervisor License

:

80-2551 Site Supervisor: Felix Gonzalez

0 ......

DSHS

Supervisor License : per supervisor Site Supervisor: Any licensed supervisor

FORM APB 5,

REV

5/07



I

1)

Below

if

Amended

E. NESHAP TRAINED

INDIVIDUAL

0 NESHAP Trained Individual: Carlos Martinez Certification Date: 04/21/14

0 NESHAP Trained Individual: Felix Gonzalez Certification Date: 03/10/14

0 NESHAP Trained Individual: Any

trained supervisor

Certification Date: per supervisor

0 F. DEMOLITION

CONTRACTOR

Demolition Contractor: NA

Address: NA

City:

NA

State: NA Zip: NA Phone : (214) 000-0000

0 G. PROJECT CONSULTANT

OR

OPERATOR

DSHS License No.: 10-0395

Project Consultant or Operator: Primera

Address: 835 E. Lamar Blvd 274

City: Arl ington State: Texas Zip: 76011 Phone : (817) 907-5993

0 ......

H.

Waste Transporter

DSHS Waste Transporter License : 40-0327

Waste Transporter: B&B

Waste Transit,

Inc.

Address: 1916 Bridgestone Drive

City:

Corinth

State: Texas Zip: 76210

Contact Person: Amy DrewPhone

:

(214) 803-3184

DSHS Waste Transporter License : 40-0355

Waste Transporter: 1 Priority Environmental Services, inc.

Address: 2573 Gravel Dr.

City: Ft. Worth State: TX Zip: 76118

Contact Person: Heath Watson

Phone :

(817) 819-6199

0 ...... 1.

Waste

Disposal Site

TCEQ Permit : 10258

FORM

Waste Disposal Site:

DFW

Landfill

Address: 1600 S. Railroad St

City: Lewisville State: Texas Zip: 75067

Phone : (972) 315-5421

CERTIFICATION STATEMENT

I hereby declare that I have examined this notification and, to the best of my knowledge and belief, all information provided is

complete, true, and correct. I affirm that I am the owner, operator, or delegated agent and that I am responsible for the fee

associated with notification. I also understand that the owner, operator, or delegated agent is responsible for notification t

the ddoartwent.

(Sign'(ture

of

Owner, Operator or Delegated Agent)

Heath Watson, for

1 PES and

agent

for

owner

(Printed Name & Title)

E-mail Address: hwatson@go 1 priority.com Phone

:

{817) 595-0790

IMPORTANT INFORMATION

NOTIFICATION TIMELINESS REQUIREMENT:

Date: 8/17/15

Your Asbestos/Demolition Notification form must be postmarked no less than ten working days (not

calendar days) prior to the start

of

any asbestos abatement or demolition.

FILING FEE: An invoice will be mailed to the facility owner upon completion of the project.

CALL FOR ASSISTANCE:

MAIL

FORM

TO:

(512) 834-6747

or(888)

778-9440 (toll free

in

Texas)

ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

PO BOX 143538

AUSTIN, TX 78714-3538



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Asbestos Notification