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SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT <br />El Northern Region Office <br />4800 Enterprise Way <br />Modesto, CA 95356-8718 <br />(209) 557-6400 • FAX (209) 557-6475 <br />(San Joaquin, Stanislaus and Merced Counties) <br />Central Region Office <br />1990 East Gettysburg Avenue <br />Fresno, CA 93726-0244 <br />(559) 230-6000 • FAX (559) 230-6062 <br />(Fresno, Madera and Kings Counties) <br />El Southern Region Office <br />2700 "M" Street, Suite 275 <br />Bakersfield, CA 93301-2373 <br />(661) 326-6900 • FAX (661) 326-6985 <br />(Tulare and Kern 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 Applicant's 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 />A , <br />Job Site Address: 1 3 5 C 0 /167 1,2 City: I,- oe I Zip Code: ,S 2/.j2 <br />Owner's name: -1-0eil 6f;d4-1-,f)e cAcs, Telephone: Fax: <br />Owner's Address: I 02 cl Ai. C 7-r7 chib dr. City S ioccroi Zip Code: 47 -5:2 04/ <br />Contractor's Name: -11.2 coc).s7-1-6/ Cr ,`O 7? Telephone: ., /7 - C') 1/,C Fax: <br />Contractor's Address: ...2 I/ 7 S---- Po f7/9 e,), City: h erC ed Zip Code: 73.cio <br />1. Facility being demolished: Yes No 2. Proposed project: Yes No <br />Single Family Dwelling or Apartment, <br />with four or fewer units. P Single Family Dwelling g <br />0 E. Subdivision, Retail or Commercial Project <br />Other (describe): eCt,--r- C / (.1 to tx) 2 ke57k00/4 5 Public Project (School, Highway, etc..) 0 la <br />Is demolition by intentional burning? ... Future use planned 1° <br />Comments: <br />aSig1turep—TiZit <br />Co n T fct.cr-crr <br /> <br />/ - - <br /> <br />Title <br /> <br />Date <br />FOR SJVUAPCD USE ONLY <br />This certifies that the demolition applicant has satisfied the APCD's notification requirements. The APCD allows the demolition to <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 notification requirements. <br />Enforcement action will be taken if asbestos NESHAP violations are found at the project. <br />Comments: <br />Printed Name: Title: <br />Approval Signature: Date: <br />Asbestos Demolition Permit Release (rev.: 10/23/2006)