Document 5bR29gZEQKxK5ydXYZQkDpaJe
ASBESTOS DEMOLITION/RENOVATION NOTIFICATION FORM
PLAINTIFF'S EXHIBIT
add change DELETE
(THIS SECTION FOR TACB USE ONLY) DISTR
* ASTERISKED ITEMS TO BE FILLED IN BY TECHNICAL SERVICES
Blue - Region/Local Green - Region/Local Canary - Data Entry Pink - Dept, of Health
CNTY: *
SOURCE: *
TACB ACCOUNT: ____-___________
PTNO: * FEDERAL FACILITY: __ (Y/N)
APST: * CMST: *"
NOTIFICATION RECEIVED DATE (MMDDYY) :____/____ /____ POSTMARK:
INVESTIGATION DATE:____/____/____
INVESTIGATOR STAFFCODE:
INVESTIGATOR JURISCODE: _________ INVESTIGATION TYPE: _____
NOV SENT DATE:____/____/____ COMPLAINT:
PSDB INV NO:
COMPLIANCE STATUS (C,N,U): ____ REVIEWER:
1) Removal Contractor: Mailing Address:
city: Corpus Christia.
TDH License No.: N/A
__________________ Phone: v.
State
_________________ Z ip:
Job Site Phone:(___
Project Supv.: Valero Refining Company
TDH License No.:
2) Other Contractor:. Mailing Address:
ML
_Phone: (
City:
State:
[____ZipT
3) Facility Owner: Valero Refining Company
Mailing Address:.
P. Q. Box 937(1
Phone: (512 ) 289-6000
City: Corpus Christ!
State:
JX.
I____ZIP:
78469_____
Principal Business:_____ Petroleum Refining
4) Description of Facility
Name:
,, ___
Address: County:_ Size:
5900 Up River Road
Nupcps
.State:
_sq. ft.
Age: _
_City: Corpus Christi
JJL
.Zip:.
784Q8
_yrs.
P^ior Use:_________________________________
5) Demolition: ____ Renovation: ____ Encapsulation:
6) Notification Type: _____ Planned
____ Renovation
_____ Emergency
10 Day Ordered
Non-Friable: _____ 20 Day
Ordered By: ______________ 7) Amount Asbestos:
linear feet (pipes)
sq.ft, (other)
8) Method Of Removal:
9) Scheduled Start Date:
_/
10) Scheduled Completion Date:____/____/.
ID Disposal Site:
Brown Ferris Industry__________________
Address:
FM 1945 and Countv Rd 39--------------------City:_
County:San PatricioState:TX
.
Phone: ( ft?) 3fid-A73? TDH/TWC Permit No: 00242
Sinton___________ _
Zip: 78387-0167
1 (Signature, Titlb of Contact)
(Date)
(Telephone Number) ACB-99
VALERO/MOAKE
57
ASBESTOS DEMOLITION/RENOVATION NOTIFICATION FORM
add CHANGE DELETE
(THIS SECTION FOR TACB USE ONLY) DISTRIBUTION
Blue - Region/Local
* ASTERISKED ITEMS TO BE FILLED Green - Region/Local
IN BY TECHNICAL SERVICES
Canary - Data Entry
Pink - Dept, of Health
CNTY: *
SOURCE: *
PTNO: *________
APST: *____
TACB ACCOUNT: ____--__ FEDERAL FACILITY: __ (Y/N) CMST: *___
NOTIFICATION RECEIVED DATE (MMDDYY) :____ /____/____ POSTMARK:____ /____ /____
INVESTIGATION DATE:____ /____/____
INVESTIGATOR STAFFCODE:
INVESTIGATOR JURISCODE: _________ INVESTIGATION TYPE:
NOV SENT DATE:____ /____ /____ COMPLAINT:____ /____/____ PSDB INV NO: ________
COMPLIANCE STATUS (C,N,U): ____ REVIEWER:
1) Remova 1 Contractor:
3AJ<z<~Ufio+J Cm*/)Any , J^AC,
Mailing Address: ~P.o. Aox /Jon*/-
9 'Phone: ( 5/2. )
City:
State: 7V
Zip:
TDH License No.:
AJfir
Job Site Phone: ( 572 ) 20`t'i><?oc?
Project Supv.:
Co . TDH License No.:____________
2) Other Contractor: Mailing Address:_
AA.
Phone:(
City:
State:
____ Zip:
3) Facility Owner:_ I/A tCAa
. //. /V 6 &*
Mailing Address:___ po A&r *n>no
Phone: {5~/z) 2S'e)-(0ooo
City: C'j.tju. t. Ckr><t\
____ State: T>c
____ Zip:_________________
Principal Business:_____ Pcmoieu^ ft*/=>a/- a'
4) Description of Facility
Name: /aUn>
)J< c
/Ia*i\s iA/SxiAAnxy {fi-fa Co~iotrio* i't<i ZepLa-McKn
Address: Sloa Up
City:'
rkn\t.
^
County:
State:
Zip:
Size:
sq.ft.
Aggee::__________________
yrs,
Prior Use:.. .__f__M__o_&_M__a__&_Y .p_G_H_T_T_*_4*j __
5) Demolition: ____ Renovation: X Encapsulation:
6) Notification Type: _____ Planned
10 Day
Renovation
Emergency
Ordered
Ordered By:
AM-
Non-Friable: _____ 20 Day
7) Amount Asbestos: <joo_ linear feet (pipes) ____ sq.ft, (other)
8) Method Of Rfiroval:
6)fitC &*<> \JJC~f /rt7H0O
9) Scheduled StPiTt Date: 10) Scheduled Completion Date:
T/ /9 / 9o
30/ 9o
11) Disposal Site:
8PZ_______________ ____
Address:______ fH /fV5~
Gqm+h KJL 3!
County: Sa*j />+*<-. e..o
Star:e:
1 XT
Phone: ( 5iz. )
TDH/TWC Permit No:
3L
(Signature,
of Contact)
yj (Date)
City: QQ 3V2_
`?t**T*7F Zip:
Or/2.) <2 21 132-f' (Telephone Number)
ACB-99
VALERO/MOAKE
58