9705-031 (DEMO)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
6 C21 t2ri.l.i� f
Date 5,?Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &. Professionals
Code).
( ) I am exempt under Section , B&P.C. for this'reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
1 have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
al,A'i'lsrfNfi
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
FINANCIAL PROPUS, INC.
ffir f
Firldnclsi Profiles Inc.----
J
Fax to number:
Attention:��,�,
Date:
From:
Number'of Pages: ! including cover
Additional comments:
L --
Financial Profiles, Inc,
5421 Avenida Encinas, Suite A
Carlsbad, CA 92008
Phone: (760) 431.9400
Fax: (760) 431-9497
M
♦. 1
UFM Joh fly: F106701C04
r�•'I�t•' f",:�� . 1��' I I (116) TT,lt•'i1
�� �•� i l ::� 1,!S fob Vt'' i 1 7 � '' i - �.. �. s k•' ti
AIR SAMPLES ANALYSIS REPORT
Rcpurt Date, 02/20/97
t; i15TOMFIR: Brickley Filvironmcrttal
Analyst; JoSI ph .luhnson 597 W. Recce Street.
San Ilcmardino, C.A. 92411 Analysis Dale: 02I14197
I'ltl)A;C'l' l,OCA`I'h:)N: Clary Hansch
50810 Jcll'eraon 5lrect
Cllt1lonterA .Mb Numbar; 1104-97 l.0 Ouintu, CA. ' Pulte Number I
Sc%WI Ilir Islunllleq were c:nllc(; Wd IiVoto Iltu allovu f0'u1:11=1 prq)Cel WI the diff-: alld I0CHOOL1B lkled below to dutcnrll- Ihu colwulm-41ion of tilwrs
ul the Mr. The samples were aualvzed using Phase Contrast Microscopy in accorduneu with NIOSII MCdIOd 7400 Wonting rules (A). If L,mpluye x
of (IIN did not collect tie xamples lixlld below, the flow rates, times, and calihrahun inl'urmaliun used to calculate the resulls were provided by the
costumer. The resines ol'tltuse Samples are rcpllrtcd in the number of fibers lixtnd in a cubic centimeter ul'air (Oru). The Slaiislieul Limit of
(luanlilivatiou is detinWl aS Rett to 1300 lilwrs lxr l;quaev millimetvr. Thl: f?PA iv:ouul1cnds' lhut the sample results Showa eleurunue level of 0.01
!'lee or less helbre clomp is considered complele. Use Ibis level as a guide to inlcrpm your clearance sample results.
SAMPLE NUMBI'?k 1 1164-01 1 1104-12 1 1164-03 1 1164-04 1 1164-051 11641-061 1161-07 1
SAMP11i DNI'fr 102/17/97 102/17/97 1 02/17/971 02/17/97102/17/97 102/17/97 102/17/971
1.1'1'1:125 of A111 1 1
1 925 1
524 j
240 1
240 1
2 190 1
k OF FIBERS 1 2.0 1
3.0 1 6.0 1
15,5 1
14,5 1
29.5 1
3.5 i
# 01; FIVIDS 1 I(IU I
!OU 1 10O 1
IPO
IOU 1
1(1() 1
10O 1
RESULTS IN I'11C'C I !
1 003 1
,1.11 j
.030 1
,060 1
002 1
RESULTS IN symm 1 1
1 7.6 1
19,7 1
18,5 1
37,5 1
6.4 I
SAMPI,V C0 Dl7.* I I
I f) 1
1) 1
r) I
I) l
A j
1104-01 - Filanlc 1164-02 - Field blank -
1164 -03
lank1164{13 - Area samplu north ol'main Lout at Decon-high vul 1164-04 • Exe during flooring mmovul,P Gurland, 526.19.44514
1 18.1-05 - personal eluring Ilosuing rumuval-p (lurlund. 510-19.4458 1164-06 - Por during window rutty rcrttovul-11 Cruz. 567-32.7654
1164-07 - Cel arancu :ample in kiluhuo
Analyzed---
Joscph Johnson
rtittmj?IC C LX{e8: F3 = Nerure nmtrvtll D = During removal A = Allcr rcmovnl
10970 Arrow Route • Suite 212 0 Rancho Cucamonga, CA 91730 0 (800) 886.2589
AIR SAMPLING DATA FORM
BRICKLEY ENWRONMENTAL
9571/!/- REECE STREET, SAN BERNA RIDNO, CA 92411 (909) 886-20 10 FAX (909) 381-3433
JOB NUMBER:
lo,
JOB NAIV
JOB LOCATION- lE-
SAMPLED BY- RELINQUISHED BYry - DATE:FER 1 8 1997
DATE: -
IDENTIFICATION
LOCATION 1 SS# I PERSON
TOTAL
FLOWRATE
I
TOTAL
COUNT
CONCLUSION
MIN.
PRE/POST
LITERS
(F/FIELD)
(FICC)
SAMPLE#: i
ST:-7
4
PUMP#-
SP:
Z--"
ROTO#:
TOJ:;
SAMPLE#-/.
ST:
PUMP#--
SP:�
ROTO#:
SAMPLE#.-
ST. fS
/0 o'
PUMP#-
SP
ROTO#-
TOT 1
.-0)
SAMPLE# -;!a
4.
ST- & -:Q I
S P
PUMP#- 5-�
04
ROTO#- 4-
8-
TOT
SAM PLE#--
PUMP#-
ST* e
Sp.
2-
2-40
l Z()
ROTO#: L-
TOT
SAM PLE#j I
3.ST:
2-LtO
2q--5 i(ob
Pump#-. ti;
At
SP-
ROTO#:
2_) Q '016
TOT 120
1_2
1
1
PLEASE DO T.W.A.
COMMENTS: c
LABORATORY NAME: f- GENERAL ENVIRONMENTAL
ANALYST- MAKMitmr--"T SERY16ES
-.A-
LABORATORY NUMBER: m_wo (CCL4-
DATE FFR 1 a 1997
w ---
CAT.JOSHA ASBESTOS NOTIFICATION
BRICKLEY ENVIRONMENTAL
t 957 WEST REECE STREET
SAN BERNARDINO, CA 92411
TEL: (909) 88-2010 FAX: (909) 381- 3433
CAL/OSHA LICENSE NO. 610414
DEPT. OF INDUSTRIAL RELATIONS ASBESTOS CERT. A-6005
ADDRESS: 242 E. AIRPORT DR. #103 ROSH REGISTRATION #49
SAN BERNARDINO, CA 92408
DATE: 2.6-97 JOB # 1164
NAME / ADDRESS OF EMPLOYER: GARY HANSCH
$421 AVENIDA ENCINA # A,
CARLSBAD, CA. 92008
ADDRESS OF JOB SITE: SUNNY DUDE RANCH
50810 JEFFERSON ST,
J.,A QUINTA, CA.
NEAREST CROSS STREET: SOTH STREET
NAME OF CERTIFIED SUPERVISOR: YORK/LARGENT/LARA/GOMEZ/BRICKLEY
NAME OF QUALIFIED PERSON IN CHARGE OF AIR MONITORING, LAB WORK AND
RESPIRATORS: AS ABOVE ANA QEM SERVICES
JOB STATE DATES ;L-A" 'I JOB COMPLETION DATE: 2.19.97
DESCRIBE SCOPE OF JOB AND WORK PRACTICES (Inc. ®q. ft.)-, SCRAPE AND REMOVE WET IN
SECTIONS AND DISPOSE OF APPROX. 600 SQ.FT. FLOOR. TILEL, MASTIC, FLEX JOINT. WINDOW
FRAMES & PUTTY FROM WINDOWS.
ESTIMATED NUMBER OF EMPLOYEES ON JOTS: 4.6
EVALUATION OF POTENTIAL FOR EXPOSURE: MINIMAL EXPOSURE - RESPIRATORS AND
PROTECTIVE CLOTHING WORN THROUGHOUT PROJECT,
TRANSPORTED BY: BRICKLEY ENVIRONMENTAL.
U.S.E.P.A. At CAL 000020974
STATE HALER42599
AND/OR
BDC SERVICES INC.
766 S. AYON, AZUSA, CA 91702
U,S.E,P.A. CAD981455520
STATE HAULER #1204
DUMP SITE: AZUSA LAND RECLAMATION CO.
1201 W. GLADSTONE STREET
AZUSA, CA 91702
CAD009007626
@E6HY f5P'RANCH
,J NON -HAZARDOUS SPECIAL WASTE & ASBESTOS MANIFEST
It waste is asbestos waste, complete Sections I, II,' III and IV. N O. d1.?
t It waste is _NM asbestos waste, complete only Sections I, II and III.
a. Generator"Name: b. Generating Location: SAME
c. Address 50810 TEEPER,S}M ST d. Address: tAMR
* f� t3[3INI'A, CA 92_2.53
e. Phone No� _ f. Phone No.:
it owner of the generating facility differs from the generator, provide:
g. Owner's Name: _
I1,' BFI WASTE CODE
In. Owner's Phone No.:
Containers
DM •METAL DRUM
DP • PLASTIC DRUM
1.ftNo. TYPE
YY B A
8 -BAG
$A"- B MIL PLASTIC BAG
or WRAP
T . ,TRUCK
O - OTHER
Ike. n0! °'wa t"dmrM i byi 40 CFA Part 284 a
Gt3nspoitatlon;acraidrp a
P ;POUNDS _
g�lydera . a iuttjees tt> pt4:Lerid o4apoeal
�. FR Pel 2" and 16 no tonper
Y -YARDS
(u CUBIC
a
• METERS
-CUBIC YARDS
'-t�eenreoo►rwa+orr�a,�gern lveme slQnatura •
n . MTWFra
S�etiohi :� .r TER _ Transporter! wm fete �i; <: -:j • •. -,,r
enerator c mDleto a ena rte ILC
RANSPORT-Gv„.,r:•;>•f":,,�i;'°=' v�"
TRANSPORTER I TRANSPORTER II
a. Name: BRICKLEY ENVIRONMENTAL' h. Name: .
b. Address: 957 N- REECE STREET i, Address;
_' -” ��N: BSi:NArRDZA10 P• -'CA. 'Y 92'�� 1• „ .:` •-� -
_-ii e.r�r.,: uarwaA7Nd�`'�"' �;-v ice+; _•:^o r lilit'��, - � --
�.: 7tlrCic NOX- `' :.
I. Dnver Name/Title:
PRINTRYPE
k. Phone No.. I. Truck No.;
m. Vehide License No,/State:
Acknowledgement of Receipt of Materials.
n.
NATION'
' (Generator cample(es a�, destination alta comp►etes'ot.) ;; •: •' ' z �w�!;� �'°i'" ;:�'� '+fhi!'�i�w(F �; ;it'
B4"UIrl11TION c. PhoneNo.: ( 818) 334-0719
-f'LA$STONE P.O. BOX 949
d. Mailing Address
SA CA. 91702 AEOSA, CA. 91702
009007826 , .. C.
`` 1
y Qj . . 7
VWtete above, named material has been accepted s of my knowledge the foregoing is true and accurate.
. � t.. t alpneture Receipt ogle
��' C• ��Y •• i i... „ ....,.•.r . Rrp.,. Q; t,: :..? i...;::: r '„'' ; _'�
OFerxtora- Name: HBA R - ENV UON�' ENTAL b. Operator's* Phone No.: ( 909) !1888-2010
�Oaerato��Address: ''937 W. REECE STREET � a 3d�N BER@r1ARDIiVO� GA. 92411 '
,.RSP�aI �rtdlin9 Bions antl additional information, Ki$EF CGVERTD IAl i`]Yt10NSPOR'1' — AV02 D OUST
bnfothis
ransponment are ilc and rldescribed
international bnroeeuati asaref and aeted,aepectoby hghway according toappi applicableadgverner mnt p .
&.TWe:
- ', Pmveype
T=
Operalor's Signature DAO
EPA 8700..-.2P r»j (Gencrarars who submit hoaardoux waste for transport QW -of -state,
produeC compl;0ed copy of this copy and send to GTSC within 30 days.)
------------------
BRICKLEY-ENVIRONMENTA
SUPERVISOR DAILY LOG SHEET
O
DATE:_ t NAME I •9 "r.'
JOB NUMBER �I�`�_ `a ] JOB LOCATION
JOB ADDRESS: ,T)`V)C> _ Q 4 �N� 5 4A Q.
- v�
uw
PRE JOB MEETING NOTES & ATTENDANCE:
PRE ABATEMENT: START,UP.CHECK ;LIST:,
YES NO NIA
1. ENTRY/EXIT LOGS, DECONTAMINATION PROCEDURES, EMERGENCY PLAN POSTED.
✓
2. JOB/EMPLOYEE FILES, EMERGENCY KIT, FIRE EXTINGUISHER ON SITE.
�r
3. RESPIRATOR BOARD UP, PROPER RESPIRATOR SELECTED/ USED,
t✓'
4. WARNING SIGNS / CRITICAL BARRIERS POSTED.
_5. AIR MONITOR ON SITE & READY.
6. WORK AREA PRE CLEANED,
�-
7. POLLY CONTAINMENT ENCLOSURE INSTALLED,
8, DECONTAMINATION SYSTEM INSTALLED AND FUNCTIONING.
8, WATER FILTRATION SYSTEM INSTALLED.
�,..
10. NEGATIVE PRESSURE ESTABLISHED.
DURING ABATEMENT CHECK.LIST:
YES NO NIA
I. RESPIRATORS & SUITS WORN BY ALL PERSONNEL IN CONTAINMENT.
2. WET REMOVAL/ PROPERLY BAGGED ACM.
3. NO SMOKING, EATING, DRINKING IN CONTAINMENT,
4. HEPA VACUUM USED.
S. CONTAINMENT BARRIER WORKING PROPERLY.
6, NEGATIVE AIR PRESSURE OPERATIONAL.
7, PERSONAL UTILIZING DECONTAMINATION SYSTEM PROPERLY.
C lm%cll,aglwlnwotdlrormsl%olg.d5
POST ABATEMENT CHECK LIST:,
YCS NO N/A
ACM DI*FINED IN SCOPE OF WORK REMOVED. '
1. ALL ACM WASTE PROPERLY PACKAGED, LADELED & MANIFESTED,
2. INGPECTION FOR RESIDUAL DEBRIS:
.A. HORIZONTAL SURFACES - I.E. - FLOORS, PIPES, VENTILATION DUCTING, ETC.
B. VERTICAL SURFACES - I.E.- WALL, REGISTERS, WINDOWS, LIGHTS, E'I'C.
3. WORK AREA ACHIEVE VISUAL CLEARANCE.
4. ENCAPSULATION OF WORK SURFACES.
5, CLEARANCE Ala SAMPLES COLLECTED. ✓
ARRIVAL TIME: 8:g,,Q DEPARTURE TIME;���,
SCOPE OF WORK/FIELD NOTES:
ill
SUPE=R�pRS -Si GN -AT
C kv:0lbcgtwm•�o�dUonneytll: JS
-- 4 r - . - - 4:—F. ——--——
SOUTk OAST AIR QUALITY MANAGEMEN'a JISTRICT
. NOTIFICATION OF DEMOUTION OR ASBESTOS REMOVAL
21865 E. Copley drive, Diamond Bar, CA 917654182_ (909) 396.2000
'A!:. k 'P"'rl rn'4?r�pY'rltl•i76r hY.r.'4 i Jrq!rt'Si?ir;d:::r )•rs,.t.,Y•5;�...: k.r<...,, .v..y..!..:.r .< .. .�r.�� •.4.?.r.!r' +., Y rr.,�:5sr,:{:,,hrA�,.;. r?r.'r:,..r,? r..r.,: :r .Y.�1wrr•[7.5::�r'��,•.��1�•1r:r i•,4�!.r r..:r 'l.h•e�, 9r?•t��{�:roy;rhhllr".ihr:�r rr'.r<r.rr,�.��. n �!.. .< n.��;�2.I�s+Y!4e.r :n.Sa.,rSk•,.r a<rr:s;:r,,.r,r.Y,?.,;.k,rW:,�i`,,�IJ •I..R...r..r.:� •..77•,.M. ,',..'. :.'•n:",..y.i:,S.yFf.:i4..f . hF. .{ .ri n'..u.r...�sr.', r'�.�.n. . ,,.r.. r.?ra.?•..t.i.r A. :.Ie..:rr.3...,T�g. r.r.rrinnyrr.T�n'r',�nFr,r.r'rrl{h..rI'r rsir..rFh..nr... >hzf,I;rq.� r;".rt..5rir..r:ai:r.i.f,i.ri.y(FF..:.wr.r.i,....r.�. .Y:.r.r��>r♦:r.r.yr.?.:'s.bxSr.r.:!.., : .?r...r.rr.r r!n.r..:,.'... ..rn•r...Sr•r.$)k.r:..t'.r2�t. :.rY.�.!.O�,rf..!rn., .....�r.r�!:..ir.n.��.r�.r ..}s.!rn�.•.i:i3..::rr.r.>rr ....�.�.i.�.t:.rrr r.,i....ryr.r k.w.,.,r. >•Ir;ris.!,�r�.•,. r.r.m.s!:..ii..'i.:ir.s:.Y�cI i.{L. 'ss rY�r:i r.i.r.n r.7:.r. r.rk..•..n�.,,:: ., 7r 7.h tL.$o.;.��¢!AS.i'r;;'�!n:ir'hY.•a.,! nnrn„Pyirrr,rr.r�,ryr..nr. .
?•P..r :. :.Y,S,h. .>r"r..:��!.n.'i¢iI'.n{kh.. �§.7'niY:ip...�.
�5rr. ',l,!�:9r,.ri.;!irr.)u:.:!•:y,i
..Y6..r.r •..}r.a„nn.r'”..Sli!
• r'4>:rr'!:n:r.�y{:r.'y":^• i>"' 7.hr: !.t.�M7. 1n.:.krr�.k. •{e.y,.rS.r.�.ry.'
Y'>..nt..ri:dP,.ri:�,iif,!4.ir:r.o-.,ilii:{rb:n,;,lrd.rr.�.i:: .:r:l.r.r;::•.r..' .1�An.ri..J.�,.f.rs.�.. nr,?t ,%r,r.. ,+t roo>rSy+�,l.r�.:o.Sr��:r:;!'.
.
BRICKL
J. OFFUTT EY
COMPLETED BY COMPANY ENVIRONMENTAL PHONE 909/888-201
:,a.:.l;rr;,;s!r.?,.t:g..1,,ii
4i�Y9ltni:r{i,:
•:.;.4.
n�t: s.•F
riyI
.,�rnrlr,.wlr ."�f.Srr.y�r S�trvu:h:
!,.b:r5.>:t5:s,4.S.;..:.di..4.r�rqn,.r;.rr/r9SS•�':4�r�;n'nprSi;?1.af'n•l�.i;r"�ri
DATE 2-5-97 CHECK # FEES 10.20 PROJECT # 1721
NOTIFICATION TYPEORIGINAL
REVISION DATES REVISION OTHER (hioilighq CANCELLATION
PROJECT TYPE
DEMOLITION ORDERED DEMOLITION RENdVATION (rEmaY EMERGENCY RENO PLANNED RENO (annum
SITE NAME SUNNY B B�� RANCH
SITE INFORMATION
SITE ADDRESS ' 50810 JEFFERSON ST CROSS STREET 50TH
CITY LA QUINTA f STATE CA ZIP e4t , __r COUNTY
DESCRIBE WORK LOCATION INTERIOR/EXTERIOR OF BUILDINGAPPROX
pp, ppppRRppgg
BUILDING SIZE (SQ M 3, 000 NUMBER OF FLOORS 1 BUELDINt� RQE IYEARB) 50 NUMBER OF DWELLING UNITS
PRESENT USE
Cawmwx HownAL INOamw-Mt8CEWWE= OFFICE REMEN SCHObL SNIP UNW.CCUM VACANT
PRIOR USE
Camotm HosmAL Now" IECgSAF1E0bs dF' m RIEWENCB >= SMP &MCCLLM VWANY
SITE OWNER ' SUNNY DUDE RANCH ADDRESS 50810 JEFFERSON ST
CITY LA QUINTA STATE CA ZIP CONTACT GARY HANSCH PHoNES19-431-9400
REQUIRED BUILDING
INFORMATION
ASBESTOS NO
PRESENT?
ASBESTOS XlfE ) NO
SURVEY?
ASBESTOS YES NO
REMOVED?
BUILDING TO BE YES N0)
bEMOLISHE=D?
DEMOLITION DATES
START END WORK SHIFT (amlpm)
REMOVAL DATES
STARTaowrrEND2-19-97 WORK SHIFT (anVpm)
ASBESTOS AMOUNT TO BE
REMOVED (in square feet
FRIABLE
CLASS I
600
CLASS 11
TOTAL REMOVED(wW rvw)
600
ASBESTOS REMOVED FROM
SURFACES PIPES COMPONENTS
DESCRIBE THE MATERIALS ACOUSTIC CEILING LINOLEUM INSULATION FIRE PROOFING DUCTING STUCCO MASTIC
FLOOR TILES .(VAT) DRY WALL PLASTER TRANSITS ROOFING OTHER (desmU) WINDOW PUTTY/FLEX JOINTS
CONTRACTOR INFORMATION
CSLB LICENSE # 610414 OSHA REG # 49 AQMD ID # 76397
NAME BRICKLEY ENVIRONMENTAL ADDRESS957 W. REECE STREET
/LACITYSAN BERNARDINO STATE CA ZIP 92411 SITESUPVR BRICKLEY/GOM ZARAPHONE909/888-201
WASTE TRANSPORTER #1BRZCKLEY ENVIRONMENTAL
LANDFILL AZUSA LAND RECLAMATION CO.
ADDRESS 957 W. REECE STREET
ADDRESS 1201 GLADSTONE AVENUE
CITY SAN BERNARDINO STATE CA ZIP 92411
ICITY AZUSA STATE CA Z%1702
Rule 1403 and NESHAP Asbestos Notilisation Form REV 9607231403FR96:SV Page 1 of 2
WASTE TRANSPORTER 92
WASTE STW SITE.
BRICKLEY ENVXRONMRNTA
ADDRESS
ADDRESS 957 W.. REECE 'STREET
CITY STATE ZIP
CITYSAN •BERNARDINO STATE CA ZIP 9
CONTROLS: DESCRIBE WORK PRACTICES AND CONTROLS TO BE USED AT THE DEMOLITION AND RENOVATION SITE. FOR ASgESTOs REMO�..
WORK, INDICATE RULE 1403 PROCEDURE 01, 2, 3, 4 OR 5 OR COMBINATIONS OF PROCEDURES USED. FOR PROCEDURES 4 AND 5, SUBMIT PL
FOR AQMD PRIOR APPROVAL. PROCEDURE k 3
ASBESTOS DETECTION PROCEDURE: DESCRIBE THE METHODS AND PROCEDURES USED TO DETERMINE WHETHER AssESTos IS PRESENT ;
THE SITE, INCLUDING THE ANALYTICAL METHODS: POLARIZED LIGHT MICROSCOPY AND DISPERSION
STAINING USING ,N.VLAP ACCREDITED LABORATORY -
FOR DEMOLITIONS GIVE= THE COMPANY NAME AND DATES OF THE ASBESTOS REMOVAL:
FOR ORDERED DEMOLITION SEND A COPY OF THE ORDER AND GIVE THE AGENCY NAME:
AUTHORIZING PERSON: TITLE
DATE OF ORDER DATE ORDERED TO BEGIN:
FOR EMERGENCY ASBESTOS REMOVAL GIVE THE NAME AND PHONE NUMBER OF THE PERSON DECLARINGIAUTHORIZING THE EMERGENCY,
AND HOUR OF EMERGENCY AND DESCRIBE THE SUDDEN, UNEXPECTED EVENT: ,
EXPLAIN HOW THE EVENT WOULD CAUSE UNSAFE CONDITIONS, EQUIPMENT DAMAGE OR UNREASONABLE FINANCIAL BURDEN:
l*fWMWff PLAN: DESCRY ACTIONS AND PROCEDURES TO BE FOLLOWED IF UNUKCTED ASBESTOS IS FOUND DURING DEMOLITION OR NONFRIABL
`ABIII
MCS VATOUAL BECOM CRUMBED, PULVERIZED, OR REDUCED TO POWDER. REVISED NOTIFICATION LETTERS WILL '
SENT IF/WHEN APPROPRIATE. REMOVAL WILL BE DONE WITHIN STATE,FED:
CAL/OSHA EPA
RULES AND REGULATIONS.
TRAINING CERTIFICATION: I CERTIFY THAT AN INDIVIDUAL TRAINED IN THE PROVISIONS OF ReGL1LATION
AQMD RULE 1403 AND NESHAP WILL BE ONSITE Cl.
THE REMOVAL AND EVIDENCE THAT THE REQUIRED TRAINING HAS BEEN ACCOMPLISHED BY THIS PERSON WILL BE AVAILABLE FOR INSKCT ION DURING NOFtlat
BUSINESS HOURS,
PRINT NAME OF OWNEWOPERATOR J OFFUTT`_011 TU oF� WNER/OPERATOR DATE $ 2-5-97
INFORMATION CFRTiFtCATlON: I CERTIFY THAT THE A®OVE INFORMATION S CORRECT AND 1 HAVE ENCLOSED ANY REQUIRED ATTACHMENTS.
J OFFUTT .
PRINT NAME OF OWNER/OPERATOR \• • IGIiI OF ERJOPE TOR DATE 2-5-97
NOTIFICATIONS -ARE NOT ACCEPTED WITHOUT THE REQUIRED ASBESTOS FEE (AQ D Rule 301). REMOVAL LESS THAN 100 SQUARE FEET ARE
MMPT FROM NOTIFICATION AND FEES.
PLEASE MAKE CHECK PAYABLE TO "SCAQMD', FEES ARE PER NOTIFICATION, NOT REFUNDABLE, A
VARY ACCORDING TO THE ASBESTOS AMOUNT TO BE REMOVED. FEES ARE AS FOLLOWS:
FROM 100 TO I.W0 SQUARE FEET $ 10.20 DEMOLITIONS $ 25.E
FROM 1,001 TO 5,000 SQUARE FEET 5 76.80 '
REVISIONS
FROM 5,001 TO 10,000 SQUARE FEET E 10.(
$179,$0 CANCELLATIONS
$ oo.c
MORE THAN 10 D00 SQUARE FEET $281,60 PROCEDURE 4 OR 5 PLANS $261.6
NOTE: STATE LAW REQUIRO THAT YOU GR A COFY OF DE110LIT1oN NOTIFICATIONS TO YOUR LOCAL BIJIUNKS AND SAFM DEPARTMFJii_ PLEmE mo t rrvr
MAIL ORIGINAL TO: SCAQMD, RULE 1403 ASBESTOS NOTIFICATIONS, P.O. BOX 4950, DIAMOND BAR, CA 9176SM50
TELEPHONE: (909) 3W23M FAX: (909) 396.3342
Rule 1403 and NESHAP Asbest