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Minnesota Pollution Control Agency 520 Lafayette Road North 5t. Paul, MN 55155-4194 Notification of Intent to Perform a Demolition Asbestos Program Doc Type: Asbestos & Demolition/Amendments Type of notification: ❑ Original ❑ Amended ❑ Project cancellation Notification must be postmarked or received ten (10) working days before demolition begins. See Item 5 for emergency demolitions. Both start and end dates should be amended in writing as necessary to reflect current project dates. Demolition Contractor Name: Address: City, State, Zip: Phone number: Contact name: Phone number: Building Owner Name: Address: City, State, Zip: Phone number: Contact name: Phone number: Building Information Building name: Address/Location: City, State, Zip: County: Phone number: Age of bldg (yrs): Number of floors, including basement level(s): Present use of bldg: Prior use of bldg: Size of bldg (sq ft): Dates of demolition or intentional burning: Start date: End date: mm/dd/yy mm/dd/yy Note: If there is >260 linear feet or >160 square feet of Regulated Asbestos -Containing Material (RACM) in the building to be demolished, it must be removed by a licensed asbestos contractor prior to demolition. The State of MN -Notice of Intent to Perform an Asbestos Abatement Project htto://www.oca.state.mn.us/oublications/w-sw4-06.doc must be used to notify for the asbestos removal. Is nonfriable ACM present in the structure to be demolished? ❑ Yes ❑ No Will nonfriable ACM be present in the structure at the time of demolition? ❑ Yes ❑ No If Yes to both questions above, complete Items 1-9. If No to either question, complete Items 3-9. 1. If ACM will be left in place for the demolition indicate the amount of Category I and/or Category II nonfriable ACM left in place. Category I: Linear feet Category II: Square feet Cubic feet Category I nonfriable ACM means asbestos -containing packings, gaskets, resilient floor covering, and asphalt roofing products containing more than one percent asbestos. Category I nonfriable ACM is not allowed to remain in place for demolition if it is in poor condition. Linear feet Square feet Cubic feet Category II nonfriable ACM_means any material, excluding Category I nonfriable ACM, containing more than one percent Asbestos that, when dry, cannot be crumbled, pulverized, or reduced to a powder by hand pressure. Category II nonfriable ACM is not allowed to remain in place for demolition if it has a high probability of becoming crumbled, pulverized, or reduced to a powder during demolition, transport, or disposal (e.g., transite, cement, slate roofing). 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 • 12/27/12 Page 1 of 2