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ASBESTOS/DEMOLITION NOTIFICATION FORM


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/.~OTIFICA TION: (Select one and fill in the requested information)


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ORIGINAL)o

AMENDMENT No._D cANCELLATION

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(!tfT~ C0 AUG 2 4 20\5/<::YV

'NCY

as emergency request made to the Regional Office or Environmental Health Notifications Group (EHNG) by phone?
DYes 0No
If yes, the DSHS reference#: _ _ and name of the Regional or EHNG representative with whom you spoke? _ _
Date: I I Time:__ Oa.m. Op.m.
Describe the reason for Emergency: _ _
0

(x)

Below if
Amended

ORDERED: (For structurally unsound facilities, attach copy of demolition order and identify Governmental Official)
Name: _ _ Registration No. _ _
Title: _ _
Date of order (MM/DD/YY): I I
Date order to begin (MM/DD/YY): I I
AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the /eft-hand side ofthis form to
indicate amended information.

'ce;~ect

TYPE OF WORK
[gj Asbestos Abatement D Demolition 0 Annual Consolidated O&M 0 Abatement/Demolition
Is this a phased project? 0 Yes [gj No
FACILITY INFORMATION
1. Facility Location
0 ....... Description or Facility Name: Former Theater
D ....... Physical Address: 1825 Abrams Rd.
D ....... County: Dallas City: Dallas Zip: 75214
0 ....... Facility Contact: Meg Robinson Phone#: 972.619.6604

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Nou"eau.
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o, Group

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2. Type of Facility (Select one)


[gj Public 0 Federal 0 Industrial/Manufacturing 0 NESHAP-Only 0 Public School K-12

0 ......
0 ......

0 ......
0 ......
0 ......
D ......
D ......
0 ......
0......

3. Facility Details
Description of Area/Room Number: Throughout Facility
Age of Building: 50+ Size: 12,000 Number of Floors:~
Is this building occupied? 0 Yes [gj No
Prior Use: Theater
Future Use: unknown
Date of Asbestos Survey/NESHAP Inspection: 7/16/14
DSHS Inspector License#: 60-0160
Analytical Method: [gj PLM 0 TEM 0 Assumed Asbestos 0 No Suspect Material
DSHS Laboratory License #: 30-0084
WORK SCHEDULE/ASBESTOS AMOUNTS (Note: if the start date(s) entered below cannot be met, the DSHS Regional or Local
Program office.J!JM!f. be notified prior to the scheduled start date. Failure to do so is a violation of TAHPA Section 295.61.)

ent Work Schedule:


nd End date: 10/2/15
0 ...... Work.~ays: [gjMop/ [gjTues. [gjWed. [gjThurs. [gjFri. 0Sat. Osun.
D ...... Work1~......:..QQ [gj a.m. 0 p.m. to 4:00 Oa.m. [glp.m.
2. Demolition Work Schedule:
0 ...... Start date: 00/NA/00 and End date: 00/NA/00
D ...... Work days: 0Mon. 0Tues. OWed. 0Thurs. 0Fri. Osat. Osun.
0 ...... Working hours: 00 [gj a.m. 0 p.m. to 00 Oa.m. [glp.m.
FORM APB #5, REV 5/07

(x)
Belo'Y if.
Amended

C. ASBESTOS AMOUNTS
0 ...... Is Asbestos Present? 1:8] Yes 0 No (Complete the table below if asbestos is present)

Asbestos-Containing Building Material Type


*Only mark the boxes below on this chart

if they are being amended

0RACM to be removed
0RACM left in place during demolition
0Interior Category I non-friable removed
0Exterior Category I non-friable removed
0Category_I non-friable left in place during demolition
0Interior Category II non-friable removed
. 0Exterior Category II non-friable removed
0Category II non-friable left in place during demolition
0RACM Off-Facility Component

Approximate amount of
Asbestos
Pipes Ln Ln Surface Area
Ft M
0
0
0

1]
[J
0

13,400

0
0

SQ
M

1:8]

0
0
0
0
0
0
0
0

1:8]

1800

[] [ J
0

SQ
Ft

[] [ J

[J

0
0
0
0
0

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DESCRIPTION OF WORK PRACTICES AND PROCEDURES


0 ...... 1. Description of procedures to be followed in the event that unexpected asbestos is found or previously non-friable asbestos
material becomes crumbled, pulverized, or reduced to powder: stop work, isolate area, clean with hepa vacuum and wet
wipe, and notify authorities.
0 ...... 2. DescriQtion of planned demolition or abatement work, type of material, and method(s): Plaster texture, duct insulation
mastic, Tire doors and flooring materials, will be bagged and disposed of as ACJ\11 m a regulated landfill. Full
contamment and with wet decon, and negative pressure will be regmred. Workers will wear full PPE.
0 ....... 3. Description of work practices and engineering controls to be used to prevent emissions of asbestos at the demolition site:
ApSiicable containments, negative r.ressuret wet removal of materials, double bagged waste for transport to approved
Jan hll. Waste transported m leak Igfit con amers.
PROJECT INFORMATION
0 ... ... A. FACILITY OWNER
Facility Owner Name: W. W. Willingham III, Trustee, Gartner 720, Ltd., K & B La Vista Texas, Ltd., K&B Collins
Texas, Ltd., K&B Josey Texas, Ltd. (as tenants-in-common, not a partnership)
Phone#: 469-688-8919
Attention: Doug Willingham
Mailing Address: 8525 Ferndale Rd., #204
City: DallasState: Texas Zip: 75238

0 ......

B. ASBESTOS ABATEMENT CONTRACTOR #1


DSHS Asbestos Contractor License#: 80-0791
Contractor Name: 1 Priority Environmental Services, Inc.
Address: 2573 Gravel Dr
City: Fort Worth State: Texas Zip: 76118
Office Phone#: (817) 595-0790 Job-Site Phone#: (817) 913-6337

0 ...... C. ASBESTOS ABATEMENT CONTRACTOR #2 (Only if there is more than one Contractor)
DSHS Asbestos Contractor License #:
Contractor Name:
Address: _ _
City: _ _ State: _ _ Zip: _ _
Office Phone #: (
)
Job-Site Phone#: ( )
D.
0
0
0

ASBESTOS SUPERVISOR
...... DSHS Supervisor License #: 80-3805 Site Supervisor: Carlos Martinez
...... DSHS Supervisor License #: 80-2551 Site Supervisor: Felix Gonzalez
...... DSHS Supervisor License #: per supervisor Site Supervisor: Any licensed supervisor

FORM APB #5, REV 5/07

(1)

Below if
Amended

E. NESHAP TRAINED INDIVIDUAL

0 ...... NESHAP Trained Individual: Carlos Martinez Certification Date: 04/21/14


0 ...... NESHAP Trained Individual: Felix Gonzalez
Certification Date: 03/10/14
0 ...... NESHAP Trained Individual: Any trained supervisor Certification Date: per supervisor
0 ...... F. DEMOLITION CONTRACTOR
Demolition Contractor: NA
Address: NA
City: NA State: NA Zip: NA Phone#: (214) 000-0000

0 ...... G. PROJECT CONSULTANT OR OPERA TOR


DSHS License No.: 10-0395
Project Consultant or Operator: Primera
Address: 835 E. Lamar Blvd #274
City: Arlington State: Texas Zip: 76011 Phone#: (817) 907-5993

0 ......

H. Waste Transporter
DSHS Waste Transporter License#: 40-0327
Waste Transporter: B&B Waste Transit, Inc.
Address: 1916 Bridgestone Drive
City: Corinth State: Texas Zip: 76210
Contact Person: Amy DrewPhone #: (214) 803-3184
DSHS Waste Transporter License#: 40-0355
Waste Transporter: 1 Priority Environmental Services, inc.
Address: 2573 Gravel Dr.
City: Ft. Worth State: TX Zip: 76118
Contact Person: Heath Watson Phone#: (817) 819-6199

0 ...... 1. Waste Disposal Site


TCEQ Permit #: 10258
Waste Disposal Site: DFW Landfill
Address: 1600 S. Railroad St
City: Lewisville State: Texas Zip: 75067
Phone#: (972) 315-5421
CERTIFICATION STATEMENT
I hereby declare that I have examined this notification and, to the best of my knowledge and belief, all information provided is
complete, true, and correct. I affirm that I am the owner, operator, or delegated agent and that I am responsible for the fee
associated with ~is notification. I also understand that the owner, operator, or delegated agent is responsible for notification to
the ddoartwent.
Date: 8/17/15
(Sign'(ture of Owner, Operator or Delegated Agent)
Heath Watson, for 1PES and agent for owner
(Printed Name & Title)
E-mail Address: hwatson@go 1priority.com Phone #: {817) 595-0790

IMPORTANT INFORMATION
NOTIFICATION TIMELINESS 'REQUIREMENT:
Your Asbestos/Demolition Notification form must be postmarked no less than ten working days (not
calendar days) prior to the start of any asbestos abatement or demolition.
FILING FEE: An invoice will be mailed to the facility owner upon completion of the project.
CALL FOR ASSISTANCE:
MAIL FORM TO:

FORM

(512) 834-6747 or(888) 778-9440 (toll free in Texas)


ENVIRONMENTAL HEALTH NOTIFICATIONS GROUP
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
PO BOX 143538
AUSTIN, TX 78714-3538

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9407 1118 99sa 2001 8548 31

CERTIFIED MAIL

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