Has ALL material of this description been removed from this room




  Notice of Asbestos-Containing Material (ACM) Removal

and

      Request for Correction of Online ACM Inventory

 
 

This form is to be completed for all asbestos abatement/removal work at the University of Maryland. It shall be submitted to the Department of Environmental Safety (DES) Occupational Safety and Health Division (FAX 301.314.9294) by the service provider for each such project, and it must be found acceptable by the DES prior to any reimbursement for the related services.  
 
 
 

Location (Building Number/Room Number(s)):  
 
 
 
 
 
 
 
 

Purpose of Removal:         Planned Renovation       Operations & Maintenance         Emergency    
 
 

 

Date(s) for Removal:   
 
 

Materials Removed (attach additional pages as necessary):

Room Number Description, size, color and type of material removed -as listed on DES inventory. (Indicate “NPL” – if described material not previously listed.) Quantity removed (“s.f.”, “l.f.” or “ea.”) Material confirmed as ACM? (Y/N) NESHAP Regula-ted? (Y/N)

(Y/N)

 Has ALL material of this description been removed from this room? (Y/N)
         
 		  
 
 		          
       
 		    
 
 		          
 
 		          
       
 		    
     
 		      
     
 		      
   
 		        

 
 

Abatement Contractor (specify company name, address, company representative and phone number): 
 
 
 
 
 
 

UM Project Manager (specify project manager’s name, phone number):  
 
 
 

Information Supplied by:       
 
 
 

Date Submitted:   
 
 






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    Has ALL material of this description been removed from this room

      Notice of Asbestos-Containing Material (ACM) Removal

    and

          Request for Correction of Online ACM Inventory

     
     

    This form is to be completed for all asbestos abatement/removal work at the University of Maryland. It shall be submitted to the Department of Environmental Safety (DES) Occupational Safety and Health Division (FAX 301.314.9294) by the service provider for each such project, and it must be found acceptable by the DES prior to any reimbursement for the related services.  
     
     
     

    Location (Building Number/Room Number(s)):  
     
     
     
     
     
     
     
     

    Purpose of Removal:         Planned Renovation       Operations & Maintenance         Emergency    
     
     

     

    Date(s) for Removal:   
     
     

    Materials Removed (attach additional pages as necessary):

    Room Number Description, size, color and type of material removed -as listed on DES inventory. (Indicate “NPL” – if described material not previously listed.) Quantity removed (“s.f.”, “l.f.” or “ea.”) Material confirmed as ACM? (Y/N) NESHAP Regula-ted? (Y/N)

    (Y/N)

    		 Has ALL material of this description been removed from this room? (Y/N)
             
         		  
     
         		          
           
         		    
     
         		          
     
         		          
           
         		    
         
         		      
         
         		      
       
         		        

     
     

    Abatement Contractor (specify company name, address, company representative and phone number): 
     
     
     
     
     
     

    UM Project Manager (specify project manager’s name, phone number):  
     
     
     

    Information Supplied by:       
     
     
     

    Date Submitted:   
     
     
    << MATERIAL TRANSFER AGREEMENT means the sale lease licence or other exploitation of the MaterialRepublic of the Philippines Department of Science and Technology >>