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>'A�i OA LTIN VALLEY UN[F] A R POLLUTION CONTROL. DISTRICT Northern Region Office Central Region Otfice E] Southern Region Office 4800 Enterprise Way 1990 East Gentysburg Avenue 2700'W Street,Suite 275 Modesto,CA 95356-8718 Fresno,CA 93726-0244 Bakers5eld,CA 93301-2373 (209)557-6400 A FAX(209)557-6475 (559)230-6000 4 FAX(559)230-6062 (661)326-6900 4 FA.X(661)326-6985 (San Joaquin,Stanislas and Merced Counties) (Fresno,Madera and Mrigs Counties) (Tulare axid Kern Counties) DE1ti1I'OLITION PEIRIMT RELEASE The pu-pose of tiis form is to verify compliance with or exemption from the National Emission Standards for Hazardous Air Pollutants asbestos notification requirements. It is the Applicant's responsibiLty to obtin the requ1i:,3-,TESHAP) ed sia abbe from the DisLLict and return this form to the Lppropriat_city,or coni ty building department prior to obtaining a demolition ern-lit. Project Description Job Site Address: Z-5 S 7 t-p , City. Zip Code: ,� f p. lj'p_, ` Telephon �=- --- e: C? =� •�7 �a. O•,vire:_name: .:� Ownc's.4ddrus y-�7,r ; �;..e�'��"�V;; `(=�' City: Zip Code: Con tractor's Name r^a �-" !-?� ��n ''= .^ elephoae: _ Fw.: - Contractor's Address: .' :.+ mit ^. ` City. --- Zip Code. I. Facili being demeidsl ed: I; 'Yes No -2. Proposed ro ect: I'es=:; '>No- Single Family Dwelling or Aparinient, ❑ Single Family D-,velling ❑ ❑ with four or fevvei units. Subdivision;Retail or Ccmmercial Project I El I ❑ Other(describe): Public Project'School,Eghwa ,etc..) I ❑ ❑ Is dernoilition by intentional burnin_s" l ❑ Future use planned I ❑ [ .:omments: r',A. f ---- -� Signature of applicant " Title - i FOR SJVUAPCD USE ONLY ❑ This certifies that the demolition applicant has satisfied the APCD's notification requirements. The APCD allows the demolition to proceed on or after ,200 ❑ This certifies that the Demolition application is exempt from the AP CD's requirements. District approval on this form only indicates compliance Tvith or exemption from tbe.NESHAP notification requirements. Enforcement action will be taken if asbestos NESHAP violations are found at the project. Cormnents: Printed Name — Title: (Approval Signature: - — Dale: -- ------ ------ —---- � J Asbestos Demolition Permit Release(rev.:10/2312006)