ࡱ> '` -xbjbj 7|-BBBB$ F,F,F,8~,<, >T:f-B/////01P9999999$;h">p99+4//+4+49BB//:363636+4B8//936+493636z36/- 3F,4366$:0T:36>G5>36>36`1v[2T362D28111995^111T:+4+4+4+4>>>$b*>>>b*D,BBBBBB  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION NEW APPLICATION FOR LICENSING AS AN ASBESTOS CONSULTANT Complete all sections of the application either by hand printing in ink or typing in the gray areas. Print out and sign the completed application and mail to Maine DEP with the appropriate application fee. Attach additional sheets as necessary. 1. Applicant:Company Name FORMTEXT  Company Address FORMTEXT  City FORMTEXT  State FORMTEXT  Zip FORMTEXT      Company Phone Number FORMTEXT  e-mail address FORMTEXT  Previous License Number (if application): FORMTEXT  Responsible Person: FORMTEXT  Title FORMTEXT  Is the applicant licensed or certified an asbestos consultant in another state?Yes FORMCHECKBOX No FORMCHECKBOX If Yes, where: FORMTEXT  License or Registration Number: FORMTEXT  2. Consultant Categories: check either A or BA)FULL FORMCHECKBOX Conducting: (Can only perform activities checked and as submitted in SOPs) FORMCHECKBOX Monitoring FORMCHECKBOX Design FORMCHECKBOX InspectionB) FORMCHECKBOX IN HOUSE IDENTIFICATION & MANAGEMENT UNIT, to conduct asbestos associated activities on owner properties only 3. APPLICATION REQUIREMENTS: An applicant for an Asbestos Consultant license must meet all the application requirements set forth below and submit attesting documentation: A. A written worker protection program including a respiratory protection program which conforms with the requirements of OSHA's Respiratory Protection Standard (29 CFR 1910.134, effective April 8, 1998); B. A medical monitoring program that conforms to the requirements of OSHA's Asbestos Standard for Construction (29 CFR 1926.1101 effective August 10, 1994), which includes the identity of the occupational health clinic utilized, number of employees enrolled in the program, and locations of employee exposure records; C. A list of all asbestos associated citations and notices of violation received in the United States during the last two years including the name of the issuing agency or department, the final disposition of such citation or notice, and, if the applicant's principal owner or operator or officer has received an asbestos associated citation or notice while owning or operating another company in the previous two years, a list of those violations; D. A list of states in which the applicant holds a license, certification, accreditation, or any other approval for asbestos abatement activity; E. A copy of the applicant's standard operating procedures including detailed summaries of standard procedures for monitoring, design and inspection; F. Sign-off form acknowledging receipt of bulk sampling and project monitoring disclosures; G. Proof of access to a licensed asbestos disposal site; H. Proof that the applicant's employees engaged in asbestos abatement activities are certified pursuant to the requirements of this Chapter; I. A list of the names of the applicant's owner(s) or operator(s), principal(s), and officer(s); J. A list of all other entities, performing asbestos abatement activities including asbestos associated activities, of which the applicant, owner or operator, principals, or officers is an owner or operator, principal or officer; K. A list of all names (or acronyms) by which the applicant's firm is known or under which it does business; L. Any information requested by the Department for purposes of determining the proficiency and adequacy of the applicant's standard operating procedures; M. Proof that the Asbestos Consultant entity works under the supervisory control of an Asbestos Abatement Design Consultant, Asbestos Inspector, or Asbestos Air Monitor as applicable; N. A statement affirming that applicable state asbestos rules and regulations, including the recordkeeping requirements of these rules, will be met; and O. Procedures for providing the State of Maine Bureau of General Services with a copy of each three-year reinspection report conducted in accordance with the requirements of AHERA within 90 days of completion of each reinspection. 4. RECORDKEEPING REQUIREMENTS: A. An Asbestos Consultant is subject to the recordkeeping requirements outlined below to the extent applicable to design, inspection, sampling, assessments, and area and clearance monitoring. B. An Asbestos Consultant must submit a statement affirming that it maintains copies of daily project logs. Past project logs must be maintained at the principal place of business. Current logs must be kept up-to-date at the project's work site. Project logs include, but are not limited to, sign-in sheets, daily project records, monitoring procedures, data, notifications, work practices associated with the asbestos activity, updated project designs indicating any changes made, and variance(s). C. An Asbestos Consultant must submit a statement agreeing to make the following documents available to the Department immediately at an active project worksite or within 24 hours of request at his/her place of business after project completion: * The name, address, and Department certification number for each of its employee's engaged in asbestos abatement activities, including dates of employment; * Identification, by name and Department certification number, of each employee's involvement in each of the Asbestos Abatement Contractor's past and present asbestos abatement projects, including name, address, location, and duration of the project; * Copies of all correspondence between the Asbestos Consultant or its agent and any asbestos regulatory agency, including but not limited to letters, notices, citations received, and any notifications made by the consultant pursuant to this Chapter; * Documents required to be maintained under any other applicable federal, state or local laws or regulations; * Copies of laboratory reports, air monitoring documents and other project documents that may be generated for a particular activity; * Copies of design documents, including implementation records, for each activity; * Copies of standard operating procedures for each asbestos associated activity performed on-site by the Asbestos Consultant; and * Copies of any other documents generated in the course of an asbestos activity. 5. FEE: The application must include a non-refundable cashiers, certified or company check in the amount of $650 dollars made payable to the Maine Environmental Protection Fund. 6. SIGNATURE: I CERTIFY UNDER PENALTY OF LAW THAT I HAVE PERSONALLY EXAMINED THE INFORMATION SUBMITTED IN THIS DOCUMENT AND ALL ATTACHMENTS THERETO AND THAT, BASED ON MY INQUIRY OF THOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE FOR OBTAINING THE INFORMATION, I BELIEVE THE INFORMATION IS TRUE, ACCURATE, AND COMPLETE. I AM AWARE THERE ARE SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT. I AM ALSO AWARE THAT ALL ASPECTS OF ASBESTOS ABATEMENT ACTIVITIES ARE SUBJECT TO INSPECTION AT ANY TIME BY THE MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION. 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