Notice of Asbestos Abatement Project

Online version of F413-025-000

 Printable instructions for how to use this form (PDF).

This notice must be received no later than 10 calendar days prior to the start date. Complete all applicable boxes. Incomplete notices will not be accepted.

To load a form you've already submitted, enter the form ID here:

Important! Project dates and work hours must be exact.

Notice Date
5/22/2013

Initial

On Hold

Emergency

Site Work Hours



(ex. 8:00 a.m.)



(ex. 5:00 p.m.)

Su
Mo
Tu
We
Th
Fr
Sa

Contractor

If you are the owner of the facility to be abated, choose "In House Work."

**NOTE: If your company is not listed, please contact L&I's Asbestos Program (360-902-5435; brandy.gaston@Lni.wa.gov). You must be a active, registered Asbestos Abatement Contractor to use this form.

Job Site C.A.S.:

Your email address: (example: myname@myisp.com)
(Note: Enter your email address if you would like a copy of this form data.)

Your phone number:

Property Owner

Name:

Company:

Owner's Agent:

Address:

City:

State:

Zip+4:

Phone:
(ex.: 123-456-7890)

Job Site

Address:

Building Name:

Room:

City:

Zip + 4:

County:

Facility

Type:

Year of Construction:

Size:

Remodel Repair Demolition Maintenance

Quantity of Asbestos to Be:

Removed Encapsulated

Quantity: (square feet)

Indoors Outdoors
Fireproofing Boiler insulation

Control Measures

Popcorn ceiling Duct paper Neg. pres. enclosure Wrap & cut
CAB VAT Glove bag Wet methods
Sheet vinyl Roofing Mini enclosure HEPA vacuum
Asbestos paper Other:
 Critical barriers Manual methods

Quantity: (linear feet)

Other:
Other:
Mag. pipe insulation Cement asbestos pipe

Respiratory Protection

Air cell pipe insulation Mudded pipe ins. 1/2 mask APR Type C continuous flow
Ducting/duct insulation Duct tape Full face APR Type C pressure demand
Other:
Other:
PAPR Other:

Any additional information? Provide it here:



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