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									        Created by Nathan Luedke
Wisconsin Department of Natural Resources



              Updated 8/05




    A Complete Notification

 A guide to filing a complete notification
               form 4500-113
                                                                          Box 1

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
 Contractor Project Number


• For the contractors use only.

• DNR does not use Contractor Project
  Number and does not record it.
                                                                  Box 2

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
          The Postmark


• The Notification must be Postmarked 10
  working days prior to the Project Start
  Date.
  –Working days include weekday
    holidays.
                    Scheduling Example
     Sunday
     Sunday        Monday
                   Monday        Tuesday
                                 Tuesday        Wednesday
                                                Wednesday          Thursday
                                                                   Thursday        Friday
                                                                                   Friday        Saturday
                                                                                                 Saturday

                                                                              1             2
                                    Because the waiting
                                    period is 10 working
3             4        5       6 days, prior to the start
                                          7        8       9

              Postmark Postmark date, the total number of
10            11       12      13
                                  calendar days will be 14 16
                                          14       15
                                       in most cases.      Start Date

17            18            19             20                 21              22            23

                            Start Date                        The exception is
24            25            26             27
                                                            when a notification
                                                               28      29                   30
                                                            is postmarked on a
                                                                  Monday.
                                                        Boxes 3 and 4

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
Date Received and DNR File #


• Used for DNR organization and filing
  purposes.

• Specific projects can quickly be found
  by referencing the DNR File Number.
                                                                          Box 5

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
     [ ] Original
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
      Type of Notification:
            Original

• First Notification for a Project.
• A Notification expires once the project
  end date passes.
• A new (original) notification must be
  filed if the first notification expires.
  – This includes 10 working day waiting
    period and fee submittal.
                                                                          Box 5

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
                     [ ] Revised
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):    1    2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
          Type of
  Notification:Revisions
• Notification must be revised if:
  – Project dates change.
     • If earlier than the original start date, must
       meet 10 working day requirement.
     • If later than the original start date, must be
       revised prior to original start date.
   – Contractor, owner, or landfill change.
   – RACM amounts change by at least 20%.
• Please highlight the word “revised”.
                                                                          Box 5

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
                                   [ ] Cancellation
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
        Type of Notification:
           Cancellations
• Cancels project.
• An “open” notification (has not expired)
  can be revised by a different entity.
• Once the notification is canceled, it can
  not be revised.
  – An original notification must be submitted
    along with 10 working day requirement
    and fee submittal.
                                                                    Box 5

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
     [ ] Emergency:Date/Hr. Notified
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
    Type of Notification:
        Emergency

• Must include date and time of
  Emergency Notice.
                                                                       Box 5

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
        [ ] Other                                                                     Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
    Type of Notification:
           Other

• Used for Courtesy Notifications,
  After-the-Fact Notifications, etc.
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____         [ ] Renovation/Abatement
                                                                                      [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
    Renovation/Abatement

• Altering a facility or one or more facility
  components in any way, including the
  stripping or removal of asbestos from a
  facility component.
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____                                       [ ] Emergency Renovation/Abatement
                                                                                      [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
          Emergency

• Emergency Notification is only for
  Renovation Projects.
• Must be a result of a sudden or
  unexpected event that causes an unsafe
  condition, equipment damage, or an
  unreasonable financial burden.
• This DOES NOT include poor planning!
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                   [ ] Planned Renovation/Abatement (Annual)
                                                                                      [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
Planned Renovation (Annual)

• Renovation projects involving
  individual, nonscheduled renovation
  operations that affect a combined
  amount of RACM which is regulated.

• Small portions of a regulated amount
  being removed over an extended
  period.
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):
                                                                                     [ ] Demolition
                                                                                      [ ] Demolition       [ ] Ordered Demolition
                                                                                      Asbestos Present? (Circle one):    Yes      No
                                                                                                                                      [ ] Fire Training Burn

 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
          Demolition

–Wrecking or taking out of any load-
 supporting structural member of a
 facility together with any related
 handling operation or the intentional
 burning of any facility.
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                                      [ ] Ordered Demolition
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
       Ordered Demolition

• A facility is being demolished under an
  order of a state or local government
  agency issued because the facility is
  structurally unsound and in danger of
  imminent collapse.
• Does not require 10 day waiting period.
• Must be notified as early as possible, but
  no later than the working day following
  the start date.
                                                                          Box 6

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes   [ ] Fire Training Burn
                                                                                                                                  No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
       Fire Training Burn

• Demolition by the intentional burning of
  a structure, used solely for live Fire
  Department training.
• The burning of a structure or building
  materials as a method of waste
  reduction or disposal is prohibited.
• Fire Training must be conducted on an
  in-tact structure and only by a Fire
  Department.
                                                                          Box 7

 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
          Inspection Dates


• Box 7 requires the dates of the
  inspection to ensure that the inspection
  is current and that it has been done.
                                                                          Box 8
 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
      Inspector Certification
           Information

• Box 8 identifies the Name of the
  inspector and their Wisconsin Inspector
  Certification Number.
• Ensures that the inspector is properly
  certified.
• Provides a contact for inspection
  information.
                                                                          Box 9
 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
  Asbestos Abatement Dates

• States the dates which Asbestos
  Abatement will take place.

• Indicates which shift the asbestos
  abatement will take place.
  – Allows the inspector to arrive during
    abatement activity.
                                                                    Box 10
 State of Wisconsin                                                                                   Notification of Demolition and/or Renovation
 Department of Natural Resources
                                                                                                             and Application for Permit Exemption
                                                                                                                  Form 4500-113 Rev 9-03                       Page 1 of 2
Notice: Completion of this form is mandatory under ch. NR 406.04, 410.05 and 447.07, Wis. Adm. Code. Penalties for failure to provide complete information
requested include forfeitures of $10 to $25,000, fines of up to $25,000 and imprisonment for up to six months. This form may be used to meet the notification
requirements for the Department of Health and Family Services, Wis. Adm. Code 159. Personally identifiable information provided may be matched with other
private, state, and federal agencies.
Submit Form: Return completed form to the appropriate office(s) listed on page 2. The DNR does not accept FAXed copies of original or revised notifications.

                                                    SHADED AREAS ON THIS FORM ARE FOR DNR USE ONLY.
1. Contractor Project #:                     2. Postmark:                   3. Date Received:                                  4. DNR File #:

 5. Type of Notification:                                                       6.    Type of Project:
    [ ] Original       [ ] Revised      [ ] Cancellation                              [ ] Renovation/Abatement         [ ] Emergency Renovation/Abatement
    [ ] Emergency: Date/Hr Notified: ______ /______ /______ _____:_____               [ ] Planned Renovation/Abatement (Annual)
    [ ] Other (Explain):                                                              [ ] Demolition       [ ] Ordered Demolition     [ ] Fire Training Burn
                                                                                      Asbestos Present? (Circle one):    Yes      No
 7. Date (MM/DD/YY) of DNR Required Pre-Project Asbestos Inspection:            8.    Inspector Certification Information:
    Start:                                  End:                                      Name:                                          WI Inspector #:
 9. Dates (MM/DD/YY) of Asbestos Abatement:                                     10.Dates (MM/DD/YY) of Renovation/Demolition:
    Start:                                  End:                                     Start:                                   End:
    Work Shift(s):   1     2   3    Weekend:                                         Work Shift(s):   1   2   3       Weekend:
 Reno/Demo (Project) Dates

• States the time frame in which the
  project is active.
• Starting before or after the specified
  start date is a violation.
• Once the end date has passed, the
  notification has expired.
  – In order to continue work, a new
    notification must be filed complete with fee
    and 10 working day waiting period.
                                                                      Box 11
11.                                Abatement Contractor:                 12.                        Demolition Contractor:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                    Telephone #:          Contact Person:                           Telephone #:
13.                                 Facility Information:                14.                            Facility Owner:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                   Telephone #:           Contact Person:                          Telephone #:
Prior Use:                                                               15.                   Waste Disposal Site/Transporter:
Present Use:                                                             Name:
Age (Yrs):                          ;    Size (Sq.Ft.):                  Address:
Number of Floors:                   ;    Number of Apartment Units:      City, St, Zip:
County:                                  DNR Region:                     Contact Person:                           Telephone #:
Number of structures to be demolished:                                   DNR License Number:
      Abatement Contractor


• Lists the abatement contractor
  information.

• Must be completed for
  Renovation/Abatement notifications or
  notice is deficient.
                                                                      Box 12
11.                                Abatement Contractor:                 12.                        Demolition Contractor:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                    Telephone #:          Contact Person:                           Telephone #:
13.                                 Facility Information:                14.                            Facility Owner:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                   Telephone #:           Contact Person:                          Telephone #:
Prior Use:                                                               15.                   Waste Disposal Site/Transporter:
Present Use:                                                             Name:
Age (Yrs):                          ;    Size (Sq.Ft.):                  Address:
Number of Floors:                   ;    Number of Apartment Units:      City, St, Zip:
County:                                  DNR Region:                     Contact Person:                           Telephone #:
Number of structures to be demolished:                                   DNR License Number:
     Demolition Contractor

• Lists demolition contractor
  information.
• May also list the Fire Department for
  a Fire Training Burn.
• Must be completed on Demolition
  notifications or notice is deficient.
                                                                      Box 13
11.                                Abatement Contractor:                 12.                        Demolition Contractor:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                    Telephone #:          Contact Person:                           Telephone #:
13.                                 Facility Information:                14.                            Facility Owner:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                   Telephone #:           Contact Person:                          Telephone #:
Prior Use:                                                               15.                   Waste Disposal Site/Transporter:
Present Use:                                                             Name:
Age (Yrs):                          ;    Size (Sq.Ft.):                  Address:
Number of Floors:                   ;    Number of Apartment Units:      City, St, Zip:
County:                                  DNR Region:                     Contact Person:                           Telephone #:
Number of structures to be demolished:                                   DNR License Number:
     Facility Information

• Includes information such as Name
  and address of the facility.
• States which DNR region it is in.
• Also requires general information
  about the structure.
• Used to generate a picture of the
  project.
                                                                      Box 14
11.                                Abatement Contractor:                 12.                        Demolition Contractor:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                    Telephone #:          Contact Person:                           Telephone #:
13.                                 Facility Information:                14.                            Facility Owner:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                   Telephone #:           Contact Person:                          Telephone #:
Prior Use:                                                               15.                   Waste Disposal Site/Transporter:
Present Use:                                                             Name:
Age (Yrs):                          ;    Size (Sq.Ft.):                  Address:
Number of Floors:                   ;    Number of Apartment Units:      City, St, Zip:
County:                                  DNR Region:                     Contact Person:                           Telephone #:
Number of structures to be demolished:                                   DNR License Number:
         Facility Owner


• General owner information and
  contacts.
                                                                      Box 15
11.                                Abatement Contractor:                 12.                        Demolition Contractor:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                    Telephone #:          Contact Person:                           Telephone #:
13.                                 Facility Information:                14.                            Facility Owner:
Name:                                                                    Name:
Address:                                                                 Address:


City, St, Zip:                                                           City, St, Zip:
Contact Person:                                   Telephone #:           Contact Person:                          Telephone #:
Prior Use:                                                               15.                   Waste Disposal Site/Transporter:
Present Use:                                                             Name:
Age (Yrs):                          ;    Size (Sq.Ft.):                  Address:
Number of Floors:                   ;    Number of Apartment Units:      City, St, Zip:
County:                                  DNR Region:                     Contact Person:                           Telephone #:
Number of structures to be demolished:                                   DNR License Number:
         Waste Disposal
        Site/Transporter

• Name and location of the waste
  disposal site.

• Used to ensure that material is being
  disposed of at licensed a landfill.
Box 16
        Amount of Asbestos
• States Categories of material and whether
  they will be removed.
• Please provide total number of each type of
  material.
   – Do not break out materials or write “see
     attached” to include each individual
     material. Use box 19 for this purpose.
• Cat I or II being removed in a manner that
  would cause it to become RACM should be
  listed as RACM.
Box 17
                 Fees


• Contains Fee Table.
• Fee structure has changed as of July 1,
  2005.
                  Suggested Fee
                    Schedule
• Demolition with less than 160 s.f., 260 l.f. of Regulated
  Asbestos Containing Material (RACM) would increase
  to $75.
• Demolition or Renovation with greater than 160 s.f.,
  260 l.f. of RACM, but less than 1000 feet combined
  would increase to $225.
• Demolition or Renovation with equal to or greater than
  1000 total feet, but less than 5000 total feet of RACM
  would increase to $400.
• Demolition or Renovation with equal to or greater than
  5000 total feet of RACM would be $750.
   Current Fees vs.
      New Fees

Previous Fees       New Fees


   $50                   $75
   $150                  $225
   $335                  $400
          New Category   $750
                                                                           Box 18
State of Wisconsin / DNR Notification of Demolition and/or Renovation and Application for Permit Exemption Page 2 of 2
18. Indicate the inspection procedure, including analytical methods, used to detect the presence or absence of the ACM




19. Description of the asbestos material involved and its location in the facility to be demolished/renovated:




20. Description of renovation/abatement and/or demolition work, including specific abatement/demolition method(s) to be used:




21. Description of abatement work practices/engineering controls and waste handling procedures, specific to this site, used in preventing ACM emissions:




22. Description of procedures to be followed if asbestos not previously identified is found or previously nonfriable asbestos becomes crumbled, pulverized or reduced to a powder:
      Inspection Methods


• Assumed materials?
• Polarized Light Microscopy (PLM)?
• Combination?
                                                                               Box 19
State of Wisconsin / DNR Notification of Demolition and/or Renovation and Application for Permit Exemption Page 2 of 2
18. Indicate the inspection procedure, including analytical methods, used to detect the presence or absence of the ACM




19. Description of the asbestos material involved and its location in the facility to be demolished/renovated:




20. Description of renovation/abatement and/or demolition work, including specific abatement/demolition method(s) to be used:




21. Description of abatement work practices/engineering controls and waste handling procedures, specific to this site, used in preventing ACM emissions:




22. Description of procedures to be followed if asbestos not previously identified is found or previously nonfriable asbestos becomes crumbled, pulverized or reduced to a powder:
     Description of Asbestos

• State detailed information about the
  type of material(s) and location(s).

• If the list is long, providing a separate
  list (“see attached”) is acceptable here.
                                                                                Box 20
State of Wisconsin / DNR Notification of Demolition and/or Renovation and Application for Permit Exemption Page 2 of 2
18. Indicate the inspection procedure, including analytical methods, used to detect the presence or absence of the ACM




19. Description of the asbestos material involved and its location in the facility to be demolished/renovated:




20. Description of renovation/abatement and/or demolition work, including specific abatement/demolition method(s) to be used:




21. Description of abatement work practices/engineering controls and waste handling procedures, specific to this site, used in preventing ACM emissions:




22. Description of procedures to be followed if asbestos not previously identified is found or previously nonfriable asbestos becomes crumbled, pulverized or reduced to a powder:
      Description of Work

• Methods of renovation/abatement.
  – Containment?
  – Glove Bag?
  – Wrap and Cut?
• Methods of Demolition.
  – Back hoe?
  – Fire Training Burn?
                                                                             Box 21
State of Wisconsin / DNR Notification of Demolition and/or Renovation and Application for Permit Exemption Page 2 of 2
18. Indicate the inspection procedure, including analytical methods, used to detect the presence or absence of the ACM




19. Description of the asbestos material involved and its location in the facility to be demolished/renovated:




20. Description of renovation/abatement and/or demolition work, including specific abatement/demolition method(s) to be used:




21. Description of abatement work practices/engineering controls and waste handling procedures, specific to this site, used in preventing ACM emissions:




22. Description of procedures to be followed if asbestos not previously identified is found or previously nonfriable asbestos becomes crumbled, pulverized or reduced to a powder:
    ACM Emission Controls

• Practices and engineering control
  being used at the site to prevent ACM
  emissions.
  – Adequate wetting.
  – Sealed in leak tight containers.
  – Negative Pressure containment.
                                                                         Box 22
State of Wisconsin / DNR Notification of Demolition and/or Renovation and Application for Permit Exemption Page 2 of 2
18. Indicate the inspection procedure, including analytical methods, used to detect the presence or absence of the ACM




19. Description of the asbestos material involved and its location in the facility to be demolished/renovated:




20. Description of renovation/abatement and/or demolition work, including specific abatement/demolition method(s) to be used:




21. Description of abatement work practices/engineering controls and waste handling procedures, specific to this site, used in preventing ACM emissions:




22. Description of procedures to be followed if asbestos not previously identified is found or previously nonfriable asbestos becomes crumbled, pulverized or reduced to a powder:
     Discovery or Condition
            Change

• Explanation of the procedure to be used if
  asbestos, previously unidentified, becomes
  visible during work.
• Also explanation of how previously non-
  friable material will be handled if it becomes
  RACM.
• Appropriate response in most cases is to stop
  work and have the situation assessed to
  reduce the risk of further contamination.
                                                                        Box 23
23. If an emergency abatement, complete the following information (attach additional sheets if necessary):
      Date and Hour of Emergency: Date (MM/DD/YY): _______ /_______ /_______ Time (12Hr Clock): _______ : _______ a.m. p.m.
      Description of sudden, unexpected event:




      Explanation of how event caused unsafe condition, potential equipment damage or an unreasonable financial burden:


24. If an ordered demolition, identify the government agency issuing the order: (Attach a copy of the order.)
      Name:                                                                                      Title:
      Authority:
      Date of Order (MM/DD/YY): __________ /__________ /__________                    Date Order to begin (MM/DD/YY): __________ /__________ /__________

25.    I certify that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on-site during the demolition/renovation and evidence that the required training has
       been accomplished by this person will be available for inspection during normal business hours.

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________

26. I certify that the above submitted information is correct to the best of my knowledge:

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________
 Emergency Abatement Info


• Date, hour, and description of incident
  or situation that caused the abatement
  to be an emergency.
                                                                                Box 24
23. If an emergency abatement, complete the following information (attach additional sheets if necessary):
      Date and Hour of Emergency: Date (MM/DD/YY): _______ /_______ /_______ Time (12Hr Clock): _______ : _______ a.m. p.m.
      Description of sudden, unexpected event:




      Explanation of how event caused unsafe condition, potential equipment damage or an unreasonable financial burden:


24. If an ordered demolition, identify the government agency issuing the order: (Attach a copy of the order.)
      Name:                                                                                      Title:
      Authority:
      Date of Order (MM/DD/YY): __________ /__________ /__________                    Date Order to begin (MM/DD/YY): __________ /__________ /__________

25.    I certify that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on-site during the demolition/renovation and evidence that the required training has
       been accomplished by this person will be available for inspection during normal business hours.

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________

26. I certify that the above submitted information is correct to the best of my knowledge:

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________
       Ordered Demolition

• Name, Authority, and Date from whom
  the Ordered Demolition originated.

• A copy of the order must be attached to
  the notification to be complete.
                                                                               Box 25
23. If an emergency abatement, complete the following information (attach additional sheets if necessary):
      Date and Hour of Emergency: Date (MM/DD/YY): _______ /_______ /_______ Time (12Hr Clock): _______ : _______ a.m. p.m.
      Description of sudden, unexpected event:




      Explanation of how event caused unsafe condition, potential equipment damage or an unreasonable financial burden:


24. If an ordered demolition, identify the government agency issuing the order: (Attach a copy of the order.)
      Name:                                                                                      Title:
      Authority:
      Date of Order (MM/DD/YY): __________ /__________ /__________                    Date Order to begin (MM/DD/YY): __________ /__________ /__________

25.    I certify that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on-site during the demolition/renovation and evidence that the required training has
       been accomplished by this person will be available for inspection during normal business hours.

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________

26. I certify that the above submitted information is correct to the best of my knowledge:

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________
  Authorized Representative


• Verifies that an authorized
  representative trained in the provisions
  of NR 447 will be on site during any
  work that disturbs RACM.
                                                                               Box 26
23. If an emergency abatement, complete the following information (attach additional sheets if necessary):
      Date and Hour of Emergency: Date (MM/DD/YY): _______ /_______ /_______ Time (12Hr Clock): _______ : _______ a.m. p.m.
      Description of sudden, unexpected event:




      Explanation of how event caused unsafe condition, potential equipment damage or an unreasonable financial burden:


24. If an ordered demolition, identify the government agency issuing the order: (Attach a copy of the order.)
      Name:                                                                                      Title:
      Authority:
      Date of Order (MM/DD/YY): __________ /__________ /__________                    Date Order to begin (MM/DD/YY): __________ /__________ /__________

25.    I certify that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on-site during the demolition/renovation and evidence that the required training has
       been accomplished by this person will be available for inspection during normal business hours.

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________

26. I certify that the above submitted information is correct to the best of my knowledge:

      Signature:                                                      Title:                                                         Date (MM/DD/YY): __________ /__________ /__________
  Certification of Information


• Verifies that all information on the
  notification is correct.
                                                                          Box 27

27. Indicate which of the following agencies/offices were sent a copy of the demolition/renovation notification. DNR has been delegated notification authority - USEPA no longer requires a copy
    of the notification. Note: Dry asbestos removal requests must be pre-approved by DNR, prior to required notification.

_____ Department of Natural Resources                                                              _____ Department of Health & Family Services
      Asbestos Coordinator, AM/7                                                                         Division of Public Health
      Bureau of Air Management                                                                           Asbestos/Lead (Pb) Section
      P.O. Box 7921                                                                                      P.O. Box 2659
      Madison, WI 53707-7921                                                                             Madison, WI 53701-2659
Copy Southeast Region if work will be conducted within Kenosha, Milwaukee, Ozaukee, Racine, Sheboygan, Walworth, Washington, or Waukesha Counties.

_____ DNR – Southeast Region
      P.O. Box 12436
      Phone: (414) 263-8500
      Milwaukee, WI 53212
         Mailing Addresses
• If a renovation involves any amount of
  asbestos, DHFS must be notified 1 business day
  before the start date.
• If a renovation has more than 160 square feet
  or 260 linear feet, it must be notified to the
  DNR and DHFS.
   – The DNR notification must be postmarked
     10 working days prior to the start date.
   – The DHFS notification must be postmarked
     10 calendar days prior to the start date.
      Mailing Notifications

• If a demolition does not involve any
  asbestos containing materials, only the
  DNR needs to receive a 10 working day
  notice.
• If the demolition does include asbestos
  containing materials, DHFS also
  requires a notification.
      Mailing Notifications

• All addresses are included on the
  notification.
• Please copy the South East Regional
  Office for DNR regulated projects.
• All fees go to the Central Office
  (asbestos coordinator) address.
                 Contacts

Mark Davis: (608) 266-3658
(Asbestos Program, Madison)                      DNR
                                                website



Nathan Luedke: (608) 264-8892
(Asbestos Program, Madison)
www.dnr.state.wi.us                             Updated
                                                  form
                                                4500-113


Department of Health and Family Services:
(608) 261-6876           www.dhfs.state.wi.us

								
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