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Home My WebLink AboutMPCA Notification m1 CONTROL AGENCY N POLLUTION Deconstruction� renovation, or C A 520 Lafayette Road North demolition notification form St.Paul,MN 55155-4194 Asbestos Program Doc Type:Asbestos&Demolition/Amendments Type of notification: ® Original ❑ Amended ❑ Project cancellation Notification is required for all NESHAP-regulated facilities,as defined in 40 CFR S 61.141,and the notification must be postmarked or received ten(10)working days before renovation,deconstruction, or demolition begins. See Item 5 for emergency demolition projects. If the project dates change, submit an amended form with an updated start and end dates to reflect current project dates. Submittal: Notifications may be made electronically(preferred)or by paper copy.To submit this form electronically, save the form to your computer and send the form to the Minnesota Pollution Control Agency(MPCA)by attaching the form to an email message, using Deconstruction, renovation, or demolition notification form(w-sw4-21)as the subject line to asbestos.demolition.pca state.mn.i.is. To submit the form by paper copy, please mail to the Asbestos Program at the address above. If you have any questions, contact the MPCA Asbestos Program Coordinator, Colin Boysen at colin.bovsen(W-state.mmus or 507-206-2644. Important Note: Ensure you are in compliance with Minn. R.7035.0805 prior to the commencement of the deconstruction, renovation or demolition project.This rule requires that the following items be removed two days prior to demolition: mixed municipal solid waste;household hazardous waste;industrial or hazardous waste;waste tires;major appliances; items containing elemental mercury, Poly-Chlorinated BiPhenyls(PCBs),and chlorofluorocarbons(CFCs);oil; lead;electronics;and other prohibited items. See MPCA website at http://www.pca.state.mn.us/publications/w-sw4-20.pdf for a Pre-Renovation/Demolition Environmental Checklist Guidance Document to assist with completion of this rule. "Demolition waste must be disposed of at a permitted solid waste facility. MPCA encourages consideration of building material reuse and recycling before demolition/disposal at a permitted solid waste facility,as outlined in in Minn. Stat. 115A.02,which establishes preferred management methods based on environmental impact. Note that some questions are optional. For more information on deconstruction/material salvage and reuse, please contact MPCA Sustainable Building Material Management staff:demo.mpca(d)_state.mn.us. Renovation, deconstruction, and/or demolition contractor If there is more than one contractor, please see last page(optional). Contractor Name of firm or organization: Mailing address: City: State: Zip code: Contact: Phone: Email: Building owner Name of owner: Caleb Petersen Mailing address: 6271 Central Ave NE City: Fridley State: MN Zip code: 55432 Contact: Phone: 7636140635 Email:_professionalgrade71 @gmail.com Building information Name of building, if applicable: Address/location: 6271 Central Ave NE County: Anoka City: Fridley State: MN Zip code: 55432 Contact: Caleb Petersen Phone: 7636140635 Email:prof essionalgrade71 @gmail.com Year built ? Size of building: 264 Sq.ft. Number of floors, including basement level(s): 1 Prior use of building Detached Garage https://www.pca.state.mn.us 651-296-6300 • 800-657-3864 Use your preferred relay service • Available in alternative formats w-sw4-21 • 9121121 Page 1 of 4 Present use of building Detached Garage Future use of building, if applicable: Dates of renovation, deconstruction or demolition: Start date: 3/30/2022 End date: 3/31/2022 (mm/dd/yyyy) (mm/dd%") Provide a brief description of the planned demolition or renovation&anticipated removal method(s): Optional for deconstruction Demolish with hand tools and power tools. Hand load into dump trailer. Haul to waste facility. If the activity was ordered by a government agency, please identify the agency and attach a copy of the order: Name: Title: Authority: Date of order(mm/dd/yy): Start date(mm/dd/yy): Notification for an emergency demolition must be submitted as early as possible before demolition begins,but not later than the following working day.A demolition is considered an emergency only when the facility has been deemed structurally unsound and in danger of imminent collapse. If the structurally unsound building is known to contain any regulated Asbestos Containing Material(ACM)or is suspected to contain any regulated ACM, special procedures must be followed. If you are unaware of the special procedures,instructions/regulations can be obtained by contacting the MPCA at the phone numbers listed below.Refer to 40 CFR 61.145(a)(3)for additional information. If the ACM will become crumbled,pulverized,or reduced to powder during the demolition process it must be removed prior to demolition activities. 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 either question above, complete Items 1-9. If No to both questions, complete Items 3-9. 1. If ACM will be left in place, indicate the amount of Category I and/or Category II nonfriable ACM left in place. Category I: Linear feet Category II Linear feet Square feet Cubic feet Square feet Cubic feet Category I nonfriable ACM means asbestos- containing packings,gaskets, resilient floor covering, Category II nonfriable ACM means any material,excluding and asphalt roofing products containing more than Category I nonfriable ACM,containing more than one percent one percent asbestos. Asbestos that,when dry,cannot be crumbled,pulverized,or Category I nonfriable ACM is not allowed to remain reduced to a powder by hand pressure. in place for demolition if it is in poor condition. 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). 2. Description and location of ACM remaining in place(including number of floors and rooms): 3. Company and/or individual that conducted the building inspection and the procedure used to determine the presence or absence of ACM (including analytic method). Note:Prior to demolition all structures must be inspected by a licensed asbestos inspector who has been certified through the Minnesota Department of Health. North Central Inspection Service LLC James Starry#All 1065 Report Attached https://www.pca.state.mn.us 651-296-6300 800-657-3864 Use your preferred relay service • Available in alternative formats w-sw4-21 • 9121121 Page 2 of 4 4. Description of procedure to be followed in the event that unexpected RACM is found or Category II nonfriable ACM becomes crumbled, pulverized or reduced to powder: Not Applicable, No RCAM was found in the entire structure 5. a. Were any materials assessed for salvaging/reuse or for recycling?(optional)❑ Yes ® No b. If yes, which ones? c. Structurelbuilding material management methods(optional). Use this section to describe the destination or end use of the materials Management method Location Material (Reused/salvaged,recycled,sent to landfill,etc. Company/Organization fCit /township, State) Concrete: Masonry: Ferrous metals: Non-ferrous metals Whole items* _ Wood Miscellaneous** *Example:fixtures, whole doors, etc. **Miscellaneous materials include shingles, drywall, carpet, etc. 6. Waste transporter information Transporter name: Homeowner is transporting waste. Mailing address City: State: Zip code: Contact: Phone: Email: 7. Permitted waste disposal site information (*see below for more information) Facility name: WM Maple Grove Transfer Station Mailing address: 10633 89'h Ave N City: Maple Grove State: MN Zip code: 55369 Contact: Phone: 9528901100 Email: Contractor signature: By typing my name below, I certify that the above information is correct and I am a bonafide representative of the demolition contractor or building owner and have authority to enter into agreements for my employer. By typing/signing my name below,I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Signature: _ Title: (This document has been electronically signed.) Date (mm/dd/yyyy): Building owner signature optional: By typing my name below, I certify that I approve of the building material management system outlined by the contractor. By typing/signing my name below,I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used for the purpose of processing this form. Signature: Caleb Petersen Title: Homeowner (This document has been electronically signed.) Date(mm/dd/yyyy): 2/28/2022 https://www.pca.state.mn.us • 651-296-6300 800-657-3864 Use your preferred relay service Available in alternative formats w-sw4-21 • 9121121 Page 3 of 4 A copy of this form should be sent to the local governing authority.Has a copy been sent? ®Yes ❑ No Check local ordinances if submittal is required,otherwise optional. "Minn. R. 7035.0805 states lead paint not firmly adhered to the substrate is required to be removed prior to demolition or renovation. For purposes of this item, 'lead paint"means a coating that contains one-half of one percent(0.5 percent)or more or 5,000 parts per million(5,000 ppm)or more of total lead by weight in the dried film, as determined by acid digestion and analysis, or contains one milligram per square centimeter(1.0 mg/cm2)or more of lead, as determined by X-ray fluorescence analyzer, MPCA encourages the proper management of lead based paint. If there's more than one contractor on this project, please list them here(optional). Contractor Name of firm or organization: Mailing address: City: State: Zip code: Contact: Phone: Email Contractor Name of firm or organization: Mailing address: City: State: Zip code: Contact: Phone: Email: https://www.pca.state.mn.us 651-296-6300 800-657-3864 • Use your preferred relay service • Available in alternative formats w-sw4-21 • 9121121 Page 4 of 4