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SAN J OAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISMCT <br /> ' Northern Region Office ❑ Central Region Office ❑ Southern Region Office <br /> 4800 Enterprise Way 1990 East Gettysburg Avenue 2700"M"Sired,Suit,275 <br /> _ Modesto,CA 95356-8718 Fresno,CA 93726-0244 Bakersfield,CA 93301-2373 <br /> (209).557-6400 o FA-X(209)557-64i5 (559)230-6000 e FAX(559)230-6067. (661)326-6900 4 FAX(661)326-6985 <br /> (San Joaquin,Sanislaus and Merced Counties) (Fresno,Madera and Kings Counties) (Tulare and Kern Counties) <br /> DEMOLITION PERMIT RELEASE <br /> The purpose of this form is to verity compliance with or exemption from the National Emission Standards for Hazardous Air Pollutants <br /> I, TSHAP) 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 Descripdon <br /> �7 - ea �4, ssz<s <br /> Job Site Address: L� 2� '�t�+e /'S S�a��� }} City. � +�, ?•t7-� Zip Cade: <br /> 0--wner's name: �.,y� Tetpbone: g 011- (-JS-'71 <br /> n <br /> Owe{s.Address: f,7+...5� 7 a is, G.D e-J . City: Zip Code: <br /> Contractor's Name: 'i'�;-la S :J?`;'�-'_1a.�-3 C.g"--s i Telephone: <br /> e <br /> Contractor's Address: 44�_ c, City: Zip Code: <br /> 1 <br /> 1. Facility being demolished: Yes No< 's. Proposed 2ro'ect: Yes No- <br /> Single Family Dwelling or Apartnent. LJ ❑ Single Family Dwelling ❑ ❑ <br /> with four or fewer units. Subdivision;Retail or Commercial Project ❑ ❑ <br /> Other(describe): Public Project(School,Highway,etc--) ❑ ❑ <br /> Is demolition by intentional burning? ❑ Future use planned ❑ <br /> -'omments: ( . [.3lzl-�el C-1 <br /> p wA+e t ('®"n-w.w'LV 4, —. <br /> Signature of applicant Title 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 NESE AP violati ons are found at the project. <br /> Co>Lnents: <br /> Pr rated Na e: Title: <br /> Approval Signature: Date: <br /> I <br /> Asbestos Demolition Permit Release(rev.: 10/23/2006) <br />