Académique Documents
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ORIGINAL)o
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as emergency request made to the Regional Office or Environmental Health Notifications Group (EHNG) by phone?
DYes 0No
If yes, the DSHS reference#: _ _ and 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
(x)
Below if
Amended
ORDERED: (For structurally unsound facilities, attach copy of demolition order and identify Governmental Official)
Name: _ _ Registration No. _ _
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 ofthis form to
indicate amended information.
'ce;~ect
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
1. 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
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3. Facility Details
Description of Area/Room Number: Throughout Facility
Age of Building: 50+ Size: 12,000 Number of Floors:~
Is this building occupied? 0 Yes [gj No
Prior Use: Theater
Future Use: unknown
Date of Asbestos Survey/NESHAP Inspection: 7/16/14
DSHS Inspector License#: 60-0160
Analytical Method: [gj PLM 0 TEM 0 Assumed Asbestos 0 No Suspect Material
DSHS Laboratory License #: 30-0084
WORK SCHEDULE/ASBESTOS AMOUNTS (Note: if the 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.)
(x)
Belo'Y if.
Amended
C. ASBESTOS AMOUNTS
0 ...... Is Asbestos Present? 1:8] Yes 0 No (Complete the table below if asbestos is present)
0RACM to be removed
0RACM left in place during demolition
0Interior Category I non-friable removed
0Exterior Category I non-friable removed
0Category_I non-friable left in place during demolition
0Interior Category II non-friable removed
. 0Exterior Category II non-friable removed
0Category II non-friable left in place during demolition
0RACM Off-Facility Component
Approximate amount of
Asbestos
Pipes Ln Ln Surface Area
Ft M
0
0
0
1]
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0
13,400
0
0
SQ
M
1:8]
0
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0
0
1:8]
1800
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0 ......
0 ...... C. ASBESTOS ABATEMENT CONTRACTOR #2 (Only if there is more than one Contractor)
DSHS Asbestos Contractor License #:
Contractor Name:
Address: _ _
City: _ _ State: _ _ Zip: _ _
Office Phone #: (
)
Job-Site Phone#: ( )
D.
0
0
0
ASBESTOS SUPERVISOR
...... DSHS Supervisor License #: 80-3805 Site Supervisor: Carlos Martinez
...... DSHS Supervisor License #: 80-2551 Site Supervisor: Felix Gonzalez
...... DSHS Supervisor License #: per supervisor Site Supervisor: Any licensed supervisor
(1)
Below if
Amended
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
IMPORTANT INFORMATION
NOTIFICATION TIMELINESS 'REQUIREMENT:
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:
FORM
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CERTIFIED MAIL
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