Annual Permit Application

The permit is effective January 1^st through December 31^st. Applicants may only renew an Annual permit, or apply for a new Annual permit, by submitting the application, applicable fees, and associated documents to the program by November 15^th of the preceding year.

Asbestos Project Contractor

Asbestos Contractor Name (Company) *

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email*

On-Site Contractor Supervisor*

First Name

Last Name

Accreditation Number*

Add Second Contractor *

Yes No

Asbestos Project Contractor 2

Asbestos Contractor Name (Company) *

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email*

On-Site Contractor Supervisor*

First Name

Last Name

Accreditation Number*

Add Third Contractor*

Yes No

Asbestos Project Contractor 3

Asbestos Contractor Name (Company) *

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email*

On-Site Contractor Supervisor*

First Name

Last Name

Accreditation Number*

Add Fourth Contractor*

Yes No

Asbestos Project Contractor 4

Asbestos Contractor Name (Company) *

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email*

On-Site Contractor Supervisor*

First Name

Last Name

Accreditation Number*

Add Fifth Contractor*

Yes No

Asbestos Project Contractor 5

Asbestos Contractor Name (Company) *

Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email*

On-Site Contractor Supervisor*

First Name

Last Name

Accreditation Number*

Building Owner Information

Owner / Owner Representative Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Asbestos Inspection Information

Asbestos Inspection Date*

Short Answer

Asbestos Inspector*

First Name

Last Name

Accreditation Number*

The above-referenced inspection report must be kept on site during the asbestos project and during subsequent renovations or demolition.

ACM Waste Transporter

Is the ACM Waste Transporter the same as the Asbestos Project Contractor?*

Yes No

ACM Transporter Name*

ACM Transporter Company*

Address Line 1

Address Line 2

City

State

ZIP Code

Company Contact Person*

Phone Number*

Email Address*

Driver Escort Name*

Accreditation Number*

Expiration Date*

Disposable Facility

Disposable Facility*

Name of Disposal Facility*

Disposal Facility Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Disposal Facility Contact Person*

Disposal Facility Contact Phone Number

Project Description

Description of work, method/s to be employed including techniques to be used and description of affected components*

Description of work practices and engineering controls to be used to comply with state and federal requirments*

Description of procedures to be followed in the event that unexpected asbestos is dicovered*

Project Designer

First Name

Last Name

Accreditation Number

Add Another Project Designer

Yes No

Project Designer 2

Project Designer

First Name

Last Name

Accreditation Number

Add Third Project Designer

Yes No

Project Designer 3

Project Designer

First Name

Last Name

Accreditation Number

Add Fourth Project Designer

Yes No

Project Designer 4

Project Designer

First Name

Last Name

Accreditation Number

Add Fifth Project Designer

Yes No

Project Designer 5

Project Designer

First Name

Last Name

Accreditation Number

Signature

Reminder

A copy of the facility's asbestos health and safety program (HASP) must be submitted to the department.

Please mail to:
Asbestos Control Program
Montana Dept of Environmental Quality
1520 East 6th Ave
Helena, MT 59620-0901

Or send via the Montana File Transfer Service:

https://transfer.mt.gov

To meet the requirements of 75-2-504, MCA, ACP will conduct a review to confirm a HASP exists for each facility permitted under an annual asbestos project permit prior to initiation of asbestos projects. DEQ’s review will focus on criteria designed to ensure the risk of exposure to asbestos is reduced at the facility and that the permitted facility continuously employs accredited asbestos workers. DEQ is not “approving” the health and safety plan and the permitee must meet all obligations under state and federal law, including OSHA.

I certify that an individual/s trained in the provisions of 40CFR part 61, subpart M will be onsite during the renovation/demolition project with the exception of demolitions where the asbestos inspection report indicates no asbestos is present; that evidence of required training accomplished by this person will be available for inspection during project work schedule; all work pursuant to the authorization of the Asbestos Project Permit/Demolition Acknowledgment will be performed in accordance with 40CFR part 61, subpart M, Montana Code Annotated §§75-2-501 through 519, Administrative Rules of Montana 17.74.301 through 406; that all asbestos containing waste materials removed during this project shall be transported properly and disposed of in an approved Class II or IV disposal facility; and that for all projects, as applicable, a copy of the application, approved acknowledgment, and asbestos inspection report/s will be posted on site on-site for the department to review.

I certify that all information herein is correct and accurate.

First Name

Last Name

Date:

Comments

Fees

Annual Permit Fee

$4,000.00

Pay By*

Credit Card Electronic Check

Json

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Site Information

Asbestos Project Contractor

Asbestos Project Contractor 2

Asbestos Project Contractor 3

Asbestos Project Contractor 4

Asbestos Project Contractor 5

Building Owner Information

Asbestos Inspection Information

Asbestos-Containing Material

Asbestos-Containing Material 2

Asbestos-Containing Material 3

Asbestos-Containing Material 4

Asbestos-Containing Material 5

Total RACM

ACM Waste Transporter

Disposable Facility

Project Description

Project Designer

Project Designer 2

Project Designer 3

Project Designer 4

Project Designer 5

Signature

Fees