CITY OF INDIANAPOLIS
ASBESTOS ABATEMENT CERTIFICATE OF OPERATION APPLICATION
New Certificate Renewed Certificate OPERATOR INFORMATION City of Indianapolis Certificate of Operation number (for renewals only): State of Indiana Contractor License number: Contractor Information:
Name of Company Mailing Address City State Zip
Change of Ownership
Expiration Date:
Phone number: Type of Ownership: Private:
Contact: Utility: State govt.: Local govt.: Federal govt.:
Complete Attachment A, describing any enforcement actions taken against the applicant for alleged violations of federal, state or local regulations pertaining to the handling, removal or disposal of asbestos containing materials. Issue Certificate to the attention of: ASBESTOS ABATEMENT EXPERIENCE AND TRAINING: Number of years operator involved with asbestos abatement: Number of employees who remove Regulated Asbestos Containing Materials: Complete Attachment B, listing all employees who have attended asbestos training courses and denoting the employees who act as project supervisors. If your firm employs more than 25 workers who remove asbestos, you may list project supervisors only.
Department of Public Works Office of Environmental Services 2700 South Belmont Avenue Indianapolis, Indiana 46221 (317) 327-2234 (fax) 327-2274 (TDD) 327-5186 indygov.org
REMOVAL AND ABATEMENT TECHNIQUES Removal and abatement techniques employed: (Check all that apply)
Critical Barriers/Isolation System With Negative-air HEPA filtration units Seal windows, doors and HVAC systems Wetting: Water Amended Water Waste Disposal: Plastic bags Drums HEPA vacuums Wet wiping and wet moping Transport in enclosed or covered vehicle Glove bag/containment bag Other removal or abatement techniques employed
Waste disposal site predominantly used: Address: Hauler primarily used: Address: The Administrative Fee of $450.00 for a Certificate of Operation must be paid before the first issuance of the Certificate and once each year when invoiced. Also, an initial non-refundable application fee of $100.00 must be paid prior to issuance of the Certificate of Operation. The Administrative Fee should be paid by check, made payable to the Indianapolis City Controller. Mail all checks to the Office of Environmental Services. I hereby certify that the above information is truthful and accurate. Signature: Printed: Title: Date
ATTACHMENT A ENFORCEMENT HISTORY
Date Citation, NOV or Other Notice Issued
Agency Issuing Enforcement Action
Regulation Allegedly Violated
Compliance Order Issued (Yes/No)
Fine or Penalty (Amount)
ATTACHMENT B EMPLOYEE TRAINING Date of Last Training Class Indiana Asbestos License number License Expiration Date
Employee Name
Supervisor or Worker