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o 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 />SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT <br />o Central Region Office 0 <br />1990 East Gettysburg Avenue <br />Fresno,CA 93726'{)244 <br />(559)230-6000 •FAX (559)230-6062 <br />(Fresno,Madera and Kings Counties) <br />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 />Job Site Address:rl'ltfO 01?tdev hq e,City:Jjo<-(CjJV1 Zip Code:95J..;S- <br />Owner's name:t/e-V;'}dVJ tfo-If w;~Telephone:'-(70 -0'3 S G,Fax:Ii S/vc/~fc;v1Owner's Address:A C),601 (872.City:Zip Code: <br />Contractor's Name:/)/1..JOtley ~'rp"C Telephone:33,{~(.J'7s:Fax:33y~]od:2 <br />Iud;Zip Code:1.5~.).c.;2.Contractor's Address:~~(S s-tXfyvd h~e,City: <br />1.Facility being demolished:Yes No 2.Proposed project:Yes No <br />Single Family Dwelling or Apartment,if D Single Family Dwelling ~0 <br />with four or fewer units.Subdivision,Retail or Commercial Project D Er <br />Other (describe):Public Project (School,Highway,etc ..)0 ~ <br />Is demolition by intentional burning?D 0"Future use planned D 0 <br />":omments: <br />I <br />"-yattJY/~W-1/vv-j.v-7 J:J~il <br />Signature of applicant (J Title Date <br />FOR SJVUAPCD USE ONLY <br />D 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 />0 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 />- <br />Printed Name:Title: <br />IApproval Signature:Date: <br />Asbestos Demolition Permit Release (rev.:10123/2006)