Agenda - Council - 11/22/2016 - Laserfiche WebLink

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2. Description and location of ACM remaining in place(including number of floors and rooms): 3. Company and/or individual that conducted the building inspection and the procedure used to determine the presence or absence of ACM (including analytic method): (Note: Prior to demolition all structures must be inspected by a licensed asbestos inspector who has been certified through the Minnesota Department of Health.) 4. Description of planned demolition and the specific method(s)that will be used: 5. If the demolition was ordered by a government agency, please identify the agency and attach a copy of the order: Name: Title: Authority: Date of order(mm/dd/yy): Start date(mm/dd/yy): Notification for an emergency demolition must be submitted as early as possible before demolition begins, but not later than the following working day.A demolition is considered an emergency only when the facility has been deemed structurally unsound and in danger of imminent collapse. If the structurally unsound building is known to contain any regulated ACM or is suspected to contain any regulated ACM, special procedures must be followed. If you are unaware of the special procedures, instructions/regulations can be obtained by contacting the Minnesota Pollution Control Agency(MPCA)at the address or phone number listed below. 6. Description of procedure to be followed in the event that unexpected RACM is found or Category II nonfriable ACM becomes crumbled, pulverized or reduced to powder: 7. Demolition waste transporter(s) information: B. Demolition waste disposal information:*see belowformore information Transporter name: Landfill name: Contact name: Owner/Operator: Tranporter address: Address/Location: City,State,Zip: City,State,Zip: Phone number: Phone number: 9. 1 certify that the above information is correct and I am a bonafide representative of the demolition contractor or building owner and have authority to enter into agreements for my employer. Print name: Title: Signature: Date: Important Note: Ensure you are in compliance with Minn. R. 7035.0805 prior to the commencement of renovation/demolition. This rule requires that the following items be removed two days prior to demolition: mixed municipal solid waste; household hazardous waste; industrial or hazardous waste;waste tires; major appliances; items containing elemental mercury, Poly- Chlorinated BiPhenyls(PCBs),and chlorofluorocarbons(CFCs); oil; lead; electronics; and other prohibited items. See MPCA website at http://www.pca.state.mn.us/publications/w-sw4-20.pdffor a Pre-Renovation/Demolition Environmental Checklist Guidance Document to assist with completion of this rule. *Demolition waste must be disposed of at a permitted solid waste facility. For other disposal option please contact the regional MPCA solid waste compliance/enforcement staff with any questions. Submit to: Minnesota Pollution Control Agency Questions call: 651-296-6300 or 1-800-657-3864 Industrial Division—Asbestos Program 520 Lafayette Road North Fax: 651-297-1438 St. Paul, MN 55155-4194 E-mail: asbestos.demolition.pca@state.mn.us www.pca.state.mn.us 651-296-6300 800-657-3864 TTY 651-282-5332 or 800-657-3864 • Available in alternative formats w-sw4-21 • 12127112 Page 2 of 2