Department of Labor Standards - Asbestos Contractor Form

Property Owner: Abatement Type: Zip Code: City: Project Address: Job End Date: Job Start Date: Reason For Waiver:

Name of Business Conducting Abatement: Contact Phone: Contact Name: Contact Email:

Invalid Phone #; Use Format: 617-626-6975

HomePage: Department of Labor Standards THE COMMONWEALTH OF MASSACHUSETTS Asbestos emergency work waiver 5/2020 Invalid Email; Use Format: name@emailprovider.com Required Required Required Required Required Required Required Required Asbestos Abatement Entity Emergency Work Waiver Request Form

Required Required Required

DEP Waiver #: Shift:

Required Required Required

Asbestos Contractor License Number:

www.mass.gov/dols

Day

Evening

Night

Invalid Zip Code Required Specific Worksite (floor #, room #, building #, etc...): CU YDS: LN FT: FT2: State: