[State of Iowa] DIAL Asbestos Permit Application

Asbestos Permit Application

Application Type

New

Renewal

Replacement

Previous Asbestos Permit Number

Expiration Date

Business Name

Business Address

City

State

Zip Code

Business Type

Sole Proprietor

Partnership

Corporation

Social Security Number

Phone Number

Mobile Number

Fax Number

Contact Name

Contact Phone Number

Name of disposal site

Address 1

Address 2

City

State

Zip Code

Name and address of other asbestos business owned or operated by any Principals in your company currently or within the past three years

Former business name and address if changed within the past five years

Other states where the business has performed asbestos removal or encapsulation in the past five years

Respiratory protection program as described in 29 CFR 1926.1101(h) and 1910.134 as applicable.
Procedures for air sampling and personal monitoring.
Medical Surveillance policy, procedures, manual or program.
Blank ten-day notice form the business will use.
Copies of all citations, violations and penalties levied against the business within the past ten years by any federal, state or local government agency for violations related to asbestos activity. Provide name and locations of the activity, date and a description of how the allegations were resolved.
Describe any civil or criminal legal proceeding, lawsuit or claim, which has been filed or levied against the business or any principals relating to asbestos activity within the past ten years.
Non-refundable $500.00 processing fee. Make check or money order payable to: Iowa Department of Inspection, Appeals, and Licensing.

Certification

I certify that the information on this form and the attachments is true and accurate to the best of my knowledge; each employee or agent of my business who will come into contact with asbestos or will be responsible for an asbestos project will first be licensed by the Iowa Division of Labor for the particular activity performed; and the business will comply with all applicable standards for removal or encapsulation of asbestos.

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