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i ,AN JOAQUIN VALLEY UNIFIE � ]��L�U��N CONTROL DISTRICT Northern Region Office Central Region Office FJ Southern Region Office 4800 Enterprise Reay 1990 East Ge-tc sburg Avenue 2700"M"Sweet,Suite 275 Modesto,CA 95356-8718 Fresno,CA 93726-0244 Pakers5eld,CA 93301-2373 (209)557-6400 6 FAX(209)557-6475 (559)230-6000 o FAX X(559)230-6062 (661)326-6900 n FA.X(661)326-6985 (San Joaquin,Stanislaus and Merced Counties) (Fresno;Madera and Kings Counties) (Tulare and Kern Counties) DEMOLITION PERMIT RELEASE The purpose of this form is to verify compliance with or exemption from the National Emission Standards for Hazardous Air Pollutants q\TESHAP) asbestos notification requirements. It is the Applicants responsibility to obtain the required signature from the District and return this foam to the appropriate city or counts building department prior to obtaining a demolition permit. �+ Project Description Job Si2eAddress: L`oma.'Z7 ?� /'S 5C_ �, City. jbjl�^fix Zip Code: �' Owner'snarne: +y-, d- Telephone Owner's Address: 10d iT—>C;m City: Zip Code: Cont z 's 1e� T � -le hone Fax: � Contractor's Address: 411S Cm- !if' ",�� City: Zip Code: I 1. Facility beim demos„-?ed: Yes No; %. Proposedproject: Yes :No Single Family Dwelling or Apartment, ❑ Single Family Dwellin ❑ ❑ with four or fewer units. LJ Subdivision.Retail or Commercial Project ❑ ❑ Other(describe): Public Project"School,Highway,etc..) ❑ ❑ Is demolition by intentional burning? ❑ ® Future use planned ❑ lomments: 1 I 4 1 signature of applicant Title ! Date 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 Mth or exemption from the NESPIAP notification requirements. Enforcement action will be taken if asbestos NESHAP violations are found at the project. Comments: Printed Name: Title: Approval Signature: --- Date: Asbestos Demolition Permit Release(rev.: 10/23/2006)