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SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT <br /> ❑ Northern Region Office L] Central Region Office Southern Region Office <br /> 4800 Enterprise way 1990 Fast Gettysburg Avenue 2700"M"Street,Suite 275 <br /> Modesto,CA 95356-8718 Fresno,CA 93726-0244 Bakersfield,CA 93301-2373 <br /> (209)557-6400 4 FAX(209)557.6475 (559)230-6000 ♦FAX(559)230-6062 (661)326-6900 ♦ FAX(661)326-6985 <br /> (San Joaquin,Stanislaus and Merced Counties) (Fresno,Madera and Kings Counties) (Tulare and Kem Counties) <br /> DEMOLITION PERMIT RELEASE <br /> The purpose of this form is to verify compliance with or exemption from the National Emission Standards for Hazardous Air Pollutants <br /> (NESHAP) asbestos notification requirements. It is the Applicants responsibility to obtain the required signature from the District and <br /> return this form to the appropriate city or county building department prior to obtaining a demolition permit. <br /> Project Description <br /> Job Site Address: 3t� y� ,� / City: S�//u1�0 / Zip Code: <br /> Owners name: �Yt 7 �//d tq Telephone: 6 U <br /> �'-"Yt_ / p r/r�—`7' �i'�, Fax: <br /> Owner's Address: .S City: , y Zip Code: <br /> Contractor's Name: (� /l//0 G>'0 (�' Telepho e f ax: <br /> Contractor's Address: City. 7ip Code: <br /> 1. Facilitybeingdemolished: 7]1 <br /> es -ffNo 2. Proposed project: Yes No <br /> Single Family Dwelling or Apartment, ._/ Sin le Famil Dwellin ❑with four or fewer un ts. LISubdivision,Retail or Commercial Project ❑ <br /> Other(describe): Public Project School,Highway,etc.. ❑ <br /> Is demolition by intentional bumuig? ❑ ElFuture use planned ❑ <br /> 'omments: <br /> r <br /> Srgrature of applicant Title Date <br /> FOR SJVIJAPCD USE ONLY <br /> ❑ This certifies that the demolition applicant has satisfied the APCD's notification requirements. The APCD allo7requirennients, <br /> proceed on or after 200 <br /> ❑ This certifies that the Demolition application is exempt from the APCD's requirements. <br /> District approval on this form only indicates compliance with or exemption from the NESHAP notificatioEnforcement action will be taken if asbestos NESHAP violations are found at the pro . <br /> Comments: <br /> Printed Name: Title: <br /> Approval Signature: Date: <br /> Asbestos Demolition Permit Release(rev.: 10/23/2006) <br /> 4 <br />