New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 369

Trenton, NJ 08625-0369

Telephone: 609-826-4950 Fax: 609-826-4975

NOTIFICATION OF NON-FRIABLE ASBESTOS WORK ACTIVITIES

RELATED TO SUPERSTORM SANDY

Must be submitted 10 days prior to the beginning of work. Please type or print legibly.

I. NOTIFICATION INFORMATION
Date of Notification:	/	/
Initial Amended Cancellation Emergency (must include justification)
Type of Work: Demolition
II. BUILDING INFORMATION
Name of Building Owner/Operator:
Street Address:	City:	State:	Zip:
Name of Contact:	Telephone No.:
III. FACILITY INFORMATION
Name of Facility Where Work Activity is to Take Place:
Describe Facility Use:
Street Address:	City:	State:	Zip:
County Name:	County Code (State Use Only):
Scheduled Start Date:	/	/	Scheduled Completion Date:	/	/
Occupancy Status During Activity (check only one):
Facility Closed/Vacated During Entire Activity
Activity Performed Outside Normal Facility Hours—Describe:
Other—Describe:
Scope of Work (check all that apply):
Floor Tile
Square Footage:
Percentage Asbestos:	%
Mastic
Square Footage:
Percentage Asbestos:	%
Transite
Square Footage:
Percentage Asbestos:	%
Roofing
Square Footage:
Percentage Asbestos:	%
Siding
Square Footage:
Percentage Asbestos:	%
Other:
Square Footage:
Percentage Asbestos:	%
IV. CONTRACTOR INFORMATION
Company Name:	Telephone No.:
Street Address:	City:	State:	Zip:
New Jersey Asbestos License Number (if applicable):
Monitoring Firm (if applicable):	Telephone No.:
V. SIGNATURE
Completed By

(type or print legibly):	Title:
Signature:	Date:

CEOH-3

APR 13

Completed By (type or print legibly): __________________________________ Title: _____________________________________

Signature:_________________________________________________________ Date: ________________________

V. Signature

Company Name:_______________________________________________________Telephone No.: _______________________

Street Address:_______________________________________ City:__________________________ State:_____Zip: ___________

New Jersey Asbestos License Number (if applicable): _____________________________________________

Monitoring Firm (if applicable): _____________________________________________Telephone No.:_______________________

IV. Contractor Information

CEOH-3, Notification of Non-Friable Asbestos work activities realted to Superstorm Sandy

EWHITE

2013-04-15

NJDOH