NOTIFICATION OF ASBESTOS ABATEMENT
(Pursuant to N.J.A.C. 7:26-2.12)

Date of Notification (1)
 Name of Building Owner/Operator (2)
Agencies Notified

( ) EPA
( ) DEP
( ) DOL
( ) DOH
( ) DCA

 Notification Type

( ) Initial Notification
( ) Amended Certification
( ) Cancelled

 Street Address
City, State, Zip Code
Name of Contact Tel. Number

FACILITY INFORMATION
Name of Facility Where Abatement is Taking Place (3) Type of Facility (4)

( ) School (K-12)
( ) Subchapter 8 (other than K-12)
( ) Other (i.e. private & commercial bldgs., homes, etc.

Sq. Feet________________ # of Floors____________

Bldg. Age_______________

Current Use (prior if being demolished)______________________________
Street Address
City (5) County (6) County Code (7)
(State Use Only)
Name of Monitoring Firm Hired by Bldg. Owner (8) ASCM No. Name of Contractor (9)
Street Address Street Address
City, State, Zip Code City State, ZipCode
Project Manager for Monitoring Firm Telephone Number Telephone Number License Number
Scheduled Start Date (10) Scheduled Completion Date (11) Name of OSHA Monitor
Occupancy Status During Abatement (Check only one)

( ) Facility Closed/Vacated During Entire Period of Abatement
( ) Abatement Performed Outside of Normal Facility Hours -

Describe________________________________________________

Other - Describe_________________________________________________

 Street Address
City, State, Zip Code
Source of Work (Check all that apply)

( ) Demolition ( ) Renovation
( ) Large Proj. (>160 SF or >260 LF ACM) ( ) SM Proj. (>25<160 SF or >10 <260 LF ACM)
( ) Minor Proj. (<25 SF or <10 LF ACM)
( ) Full Containment with Negative Pressure ( ) Mini-Enclosure ( ) Glovebag Procedure
Location of Asbestos-Containing Material (ACM) in Facility (13) Is Location Normally Used Solely by Maint./Custodial Staff? (12) Description of ACM (i.e. thermal systems insulation, surfacing, VAT, or other miscell.) Amount (Specify SF or LF) Abatement Type
YES NO NA Rem. Rep. Encap Enclose
Name of Reg. Waste Hauler NJDEP Waste Hauler ID # Cubic Yards of Waste Name of Reg. Landfill
City, State Disp. Date City, State
Completed by (Print or Type) Title Signature Date
Mail to: NJDEP-DSHW-BRRTP
              401 E. State St., PO 414
              Trenton, NJ 08625-0414
              Telephone 609-984-6620		 9/18/00