Application Checksheet For Asbestos Contractor {52571}

APPLICATION CHECKSHEET FOR ASBESTOS CONTRACTOR State Form 52571 (2-06) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT NOTE: DO NOT RETURN THIS SHEET WITH APPLICATION This checklist is used by IDEM to review your Form 48739 "Application for Asbestos Contractor License" and is provided only to assist you in compiling a complete Standard Operating Procedures manual for submittal with the asbestos contractor license application. IDEM ­ Office of Air Quality Asbestos/Lead Program 100 N. Senate Avenue Indianapolis, IN 46204-2251 Phone: (317) 233-3861 or 1-888-574-8150 (Nationwide) http://www.IN.gov/idem/permits/air FOR OFFICE USE ONLY Company Name: Applicant Name: Designated Employee Name: Reviewed by: Date reviewed: TYPE OF LICENSE NEW LICENSE STATUS OF LICENSE APPROVED DENIED PENDING ADDITIONAL INFORMATION RENEWAL LICENSE - Expiration Date: ____/____/____ PART A: APPLICATION The following items have been completed on, or attached to, the license application? YES NO RULE REQUIREMENT ­ to be completed on or attached to application GENERAL INFORMATION AND ATTACHMENTS 326 IAC 18-1-5(b)(1) General and personal information provided If no, provide the following: __________________________________________________________ Proof of financial responsibility attached Verified: _________________________________________________________________________ Required Training Attended an Indiana-approved asbestos Project Supervisor or Contractor training course and received a passing score on the final written exam during the twelve months prior to application submittal. Contractor may designate an employee to fulfill this training requirement. **New applicants should submit a copy of their initial Supervisor/Contractor training course certificate and each annual Supervisor refresher course certificate received thereafter. There should be no more than 18 months between the starting date of each course. Applicant must have taken and passed the final written exam for the initial course and each refresher course. Verified:_________________________________________________________________________ Training Certificates Copy of training certificate(s) attached *Initial course certificate *Refresher course certificate(s) 326 IAC 18-1-5(b)(10) 326 IAC 18-1-4(g)(2) 326 IAC 18-1-5(b)(3) Standard Operating Procedures (SOP) Manual Copy of contractor's written standard operating procedures for the following regulatory programs is attached: 326 IAC 14-10; 326 IAC 18-1; 329 IAC 10-8-4; 29 CFR 1926.1101; 29 CFR 1910.134. 326 IAC 18-1-5(b)(5) NOTE: Do not attach copies of these rules and regulations. Instead, the SOP manual should include detailed, specific written procedures for contractor's compliance with Indiana's asbestos rules. This includes notification, work practice, and licensing requirements. 326 IAC 18-1-5(b)(1) 326 IAC 18-1-5(e) 326 IAC 18-1-5(b)(1) 326 IAC 18-1-9(a)(4) White colored lead signature cards signed and attached Two 1-½ inch by 1-½ inch recent color photographs of applicant attached Application signed Application fee of $150 submitted with application Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 52571 (2-06) Application Checksheet For Lead Contractor 8/01 PART B: STANDARD OPERATING PROCEDURES MANUAL (SOP) Has contractor included in the SOP their procedures for compliance with the following rules? YES NO RULE REQUIREMENT - to be addressed in the SOP 326 IAC 14-10 APPLICABILITY OF RULE Demolitions 260 LF, 160 SF, or 35 CF friable ACM Demolitions < 260 LF, 160 SF, or 35 CF friable ACM Ordered Demolitions Renovations 260 LF, 160 SF, or 35 CF friable ACM Renovations < 260 LF, 160 SF, or 35 CF friable ACM Emergency Renovations 326 IAC 14-10-1 DEFINITIONS Adequately wetted RACM Asbestos removal project Friable 326 IAC 14-10-2 NOTIFICATION REQUIREMENTS/CONTENTS/SCHEDULE/FORM 326 IAC 14-10-3 State of Indiana Indianapolis Air Pollution Control Division ASBESTOS EMISSION CONTROL Remove all RACM prior to demolition/renovation and exception When removing components as unit or in sections Adequately wet ACM when being stripped before members removed from facility; wetting exemptions When component taken out of facility as unit or in sections For large facility components For all RACM materials that have been removed or stripped When temperature at point of wetting is <32 degrees Fahrenheit Ordered demolitions Upon completion of stripping and removal operations Upon completion of cleanup requirements For any RACM or suspect RACM stored elsewhere Facility demolished by intentional burning Indiana licensed Project Supervisor on site 326 IAC 14-10-4 NOTIFICATION FEES 326 IAC 14-10-5 for demolitions for renovations 326 IAC 18 INDIANA LICENSED PERSONNEL 326 IAC 18-1 At least one Indiana-licensed Project Supervisor in work area Current Indiana licenses on site Valid photo IDs on site 329 IAC 10-8-4 WASTE MANAGEMENT 329 IAC 10-8-4 Disposal of waste in Indiana in IDEM-approved landfill Labeling (40 CFR 61, Subpart M, 11/20/90) OSHA "danger", generator, transporter & DOT IDEM's waste shipment record 29 CFR 1910.134 RESPIRATORY PROTECTION STANDARDS 29 CFR 1910.134 Respiratory Protection Standards Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT OFFICE OF AIR QUALITY State Form 52571 (2-06) Application Checksheet For Lead Contractor 8/01 YES NO RULE REQUIREMENT - to be addressed in the SOP 29 CFR 1926.1101 CONSTRUCTION STANDARD Permissible exposure limit Regulated areas Exposure monitoring Engineering controls and work practices Respiratory protection Protective clothing Clean change areas Hazard communications to employees Medical surveillance 29 CFR 1926.1101 INDIANAPOLIS AIR POLLUTION CONTROL BOARD REGULATION XIII Asbestos Abatement 4/4/88 for Facilities in Marion County, Indiana IAPCB Regulation XIII Statement that valid certificate of operation will be obtained by contractor prior to implementing projects in Marion County. DEMONSTRATED COMPETENCY (326 IAC 18-1-4(g)(3)) Has contractor demonstrated competency in the field of asbestos project implementation, and has contractor provided the following information? 326 IAC 18-1-5(b)(4) 326 IAC 18-1-5(b)(6) 326 IAC 18-1-5(b)(7) 326 IAC 18-1-5(b)(8) A complete list of prior contracts for the previous 12 months for asbestos projects including names, addresses and telephone numbers of persons for whom projects were performed. A