Panhandle Pumping Inc.

Serving Jefferson County, WV and Berkeley County, WV with their roll off dumpster rental needs.

Asbestos Form

Date:(Required)

Waste Generator Location:(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Contact Name:(Required)

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1. What Type of Structure is the Generator Location (check one)?(Required)

Residence (single dwelling or residential building with 4 or fewer units).

Any group of buildings or structures at a single demolition or renovation site under the control of the same owner or operator, including residential homes.

Commercial/Business Facility.

School or Certified Learning Center.

2. Has an Asbestos Survey been completed prior to all construction, demolition or renovation activities identifying all materials contained within the structure?(Required)

YES (attach survey/lab results//supporting documentation)

If YES, attach survey/lab results//supporting documentation(Required)

Max. file size: 8 MB.

If NO, explain why not:(Required)

3. Was Asbestos Containing Material (“ACM”) identified within the structure(s)?(Required)

YES

If YES, explain management procedures (removal, packaging, transportation, disposal):(Required)

I hereby certify that based upon my personal knowledge and information, No Unacceptable Materials** are included within the waste materials to be disposed of within LCS Landfill.

Signature(Required)

Name(Required)

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Date:(Required)

** West Virginia Title 33, Legislative Rule, Department of Environmental Protection, Waste Management, Series 1, Solid Waste Management Rule, Subdivision 2.38, states that acceptable “Construction/Demolition Waste” shall mean waste building materials, packaging, and grubbing waste resulting from construction, remodeling, repair, and demolition operations on houses, commercial, and industrial buildings, including, but not limited to, wood, plaster, bricks, blocks and concrete, and other masonry materials, but does not include any Unacceptable Materials, which shall mean Asbestos-Containing Materials, household furnishings, burnt debris, material containing lead-based paint, pressure-treated wood, contaminated solid waste, yard waste or waste tires, and other items listed in Subdivision 5.4a.

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