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1
Hazardous Materials Issues on Bridge Projects
February 15, 2018
E. Brett Waller
Hazardous Materials Manager, Staunton Environmental
Two Ways of Learning
“Case-Study” ApproachMemorization of Specific Examples
“First Principles” ApproachUse Applicable Principles to Evaluate What Will Happen
2
2
3
Outline of Presentation
• Safety: Personal Protection & Source-Pathway-Receptor Model
• Waste: Solid vs. Hazardous Waste – Handling, Disposal & Documentation
• Asbestos on Bridges: Identification, Removal & Disposal
• Lead-Based Paint: Identification, Appropriate Work Methods, Road & Bridge Specifications, State/Federal Regulations
• Demolition: Handling of Materials, DOLI Notification
Part 1: Safety
4
3
Objective
Explain the Principles that Affect Personal Exposure to Chemicals or Other Hazards
Understand How to Evaluate Risk of Exposure
Use these Principles to Eliminate or Minimize your Risk from Potential Exposure to Hazards
Apply these Principles to Evaluate Engineering Controls for Environmental Protection on Bridge Projects
5
The SPR Model for Exposure
Simplified Representation of the Incident
Framework for Organizing your Thoughts
Components of Model
• Source
• Pathway
• Receptor
6
4
Source
The Chemical or other Substance Capable of Doing Harm
Source is “Normally” Under Engineering Controls
An “Incident” is an Uncontrolled Situation
Potential Sources on Bridge Projects:
Diesel Fuel, Hydraulic Fluid, Paint, Solvents, other Chemicals
Bridge Coatings (Lead, Chromium, Cadmium, Arsenic), Asbestos, & Silica
Galvanizing / Zinc Additives, Shotcrete, Residues from Bridge Washing
7
Receptors
The Entity that is at Risk from the Source
Human Receptors
Environmental Receptors
Examples of Receptors
YOU !! – Personal Safety is Job #1
Employees (VDOT / Contractors) & Families
General Public
Ecosystem or Habitat (Terrestrial or Marine)
8
5
Pathway = Route of Exposure
The Transport Mechanism by which the Hazard presented by the Source reaches the Receptor and does Harm
Routes of Exposure for Human Receptors
Inhalation: Move Upwind, Exit Area, or use PPE
Ingestion: Eliminated by Strict Observance of Hygienic Practices
Absorption: Hand and Eye Protection, Cover Exposed Skin
Injection: Avoid Punctures, Cuts, or Scrapes
9
Technical Schematic of Model10
6
Protection: Risk Reduction or Removal& Prevention of Harm
Source Control or Removal: • Isolation
• Clean-Up
• Abatement / Remedial Measures
Pathway Elimination, Modification or Control:• Engineering Controls / Containment
• Personal Protective Equipment
• Location of Materials
Receptor Protection:• Leave “Danger Zone”
• Work “Up Wind”
• Minimize Exposure Time
11
Any Potential Risks?12
7
Easily Recognized Injection Hazard13
Greenbrier
Easily Overlooked Injection Hazard
14
8
Sources of Information for Chemicals
o Product Label
o Safety Data Sheet (SDS, formerly MSDS)
o Personal Knowledge of Material
o Safety / Environmental Staff
15
Safety Data Sheet (SDS)Example
16
9
Mystery Chemical Is:
Safety Data Sheet (SDS)Example
17
Example Scenario
What are the Potential:
Sources?
Receptors?
Pathways?
Bridge Replacement Project
• Staging Area in Field to North
• Materials Storage & Fueling
18
10
End of Part 1: Safety
19
Questions or Comments??
Part 2: Waste Materials
20
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SOLIDWASTES
HazardousWastes
UniversalWastes
Recycled &ReclaimedMaterials
PRODUCTS(useful life)
Types of Waste Materials
Resource Conservation & Recovery Act (RCRA)
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A VDOT “Waste Area” should NOT contain Solid Waste !!
Hazardous Waste is a Solid Waste which is either a:
Listed Hazardous WastesEPA Includes on Lists of Hazardous Wastes
or
Characteristic Hazardous WastesIgnitable (gasoline, solvents)Reactive (e.g. water reactives)Corrosive (acids / bases)Toxic (39 constituents, e.g. lead)
22
12
The “Generator” of a Hazardous Waste is:
“any person, by site, whose act or process produces hazardous waste … or whose act first causes hazardous waste to become subject to regulation”
Applies to both VDOT and the Contractor
Responsible for proper Handling & Transport • EPA Identification Number
• Uniform Hazardous Waste Manifest
Waste Determinations are Based on Generator Knowledge or Testing
23
Risk Model for the Toxicity Characteristic Leaching Procedure (TCLP)
24
500 feet
MCL at WellMaximum
Contaminant
Level
Leachate Concentration
DAF = 100Dilution
Attenuation
Factor
13
Laboratory AnalysisTCLP and Total Metals
25
Testing Requirement for TCLP in R&B Specifications 411.09(c)
Uniform Hazardous Waste Manifest
Required to Transport Hazardous Waste
Must receive Signed Copy within 45 days of Shipment
Begin Inquiry 35 days after Shipment if Manifest not
Received
Requirement to Manage
“Cradle-to-Grave”
Required Documentation
for Disposal Pay Item
R&B Specifications 411.09(d)
26
14
End of Part 2: Waste Materials
27
Questions or Comments??
Part 3: Asbestos on Bridges28
15
Asbestos – What is it? A naturally occurring mineral that is mined and has been used in
thousands of commercial products
29
Thetford Mines, Quebec
Asbestos Characteristics
Properties of Asbestos fibers:
• High Tensile Strength• Chemical / Thermal Resistance• High Electrical Resistance• Can be Woven
There are ~300 asbestiform minerals; these six are legally
defined as ASBESTOS
Asbestos is made up of fiber bundles.
30
16
Use of Asbestos
Fibrous minerals were processed into products.• Provides fire-proofing• Increased mechanical strength
These products are known as Asbestos-Containing Materials (ACMs)
Manufacture and use of asbestos peaked in 1973 in USA• EPA increasingly banned uses from 1973-1989• Comprehensive 1989 ban was overturned in 1991
*** You can still purchase ACM today = Caveat emptor
31
Asbestos Regulatory Basics
EPA – NESHAP, 40 CFR Part 61
ACM – contains more than 1% asbestos
Friable – ACM that “when dry, can be crumbled pulverized, or reduced to powder by hand pressure”
Non-friable (NF) – ACM that “when dry, cannot be crumbled pulverized, or reduced to powder by hand pressure”
32
17
Exposure to Asbestos
•Asbestos Containing Materials (ACMs) may release fibers when disturbed
•Microscopic fibers stay airborne for a long time
•Easily inhaled and can damage the lining of the lungs
Asbestos in NOT Kryptonite
Proximity is not a hazard, as long as ACM is not disturbed and does not release fibers
RESPIRATORY HAZARD !!
33
Identifying Asbestos on Bridge Structures
Anything other than Concrete, Metal, Asphalt, Plastic, and Rubber
is considered Suspect Asbestos-Containing Material (ACM)
All Interstate & Most Primary Bridges have Suspect ACM • Approximately 5% of suspect ACM will contain Asbestos
All Bridges should be inspected for Asbestos prior to Work• Bridge Screening Checklist (minimum for planning purposes)
• Consultant Asbestos Inspector
• Environmental Section
• Specify Contractor to Perform Inspection
Check Structure & Bridge Database to determine if the bridge has been screened and/or inspected for asbestos
Review available Plan Sheets for the Bridge
34
18
Transite Conduit
Asbestos-Cement Pipe
Chrysotile Asbestos + Binder
35
Johns-Manville Transite
Flintite A-COrangeburg USA
35
Non-Metallic Electrical Conduit
Non-metallic electrical conduit is commonly Transite
on older bridge structures
36
19
Rail Posts on Interstate Bridges
37
Rail Post Pads
Modern
“Duct Tape”
Repair38
Arrangement of Pads in the Post
38
20
Bridge Joints39
Bearing Surfaces
40
21
Mastics / Caulks
41
41
Silver Paint42
22
Drains&
MiscellaneousMaterials
43
Laboratory Confirmation of Asbestos
Polarized Light Microscopy (PLM)
for Bulk Samples
44
Phase Contrast Microscopy (PCM)for Air Samples
44
23
End of Part 3: Asbestos on Bridges
45
Questions or Comments??
Part 4: Bridge Coatings / Lead-Based Paint (LBP)
46
24
Concerns withLead-Based Paint (LBP)
used on Bridge Structures
Lead was historically used as an Additive in many Industrial Coatings
Lead is Toxic to Humans & the Environment
Requires Special Procedures to Protect Workers & the Environment
Projects may generate Hazardous Waste
47
48 Flow Chart for Bridge Projects
In General:
Bridge Painting >> 100 ft2
Demolition – depends on Length of the Structure,
but often < 100 ft2
> 100 ft2 < 100 ft2
25
Projects Involving Lead-Based Paint
Type B Structures – “Steel Structures that have existing coatings.”
Applicable R&B Specifications include:
411.01 - Type A/B
411.03 - Certifications
411.04 - Surface Prep
411.09 - Env Plan
411.10 - H&S Plan
413 - Demolition
107.16 - Env Requirements
49
Certifications: Section 411.03
SSPC QP-1, Standard Procedure for Evaluating Qualifications of Industrial/Marine Painting Contractors, usually designated on certificate as Field Application of Coatings, Complex Structures
SSPC QP-2, Standard for Evaluating Painting Contractors , Removal of Hazardous Coatings from Industrial/Marine Steel Structures, usually designated on certificate as Industrial Hazardous Paint Removal
SSPC QP-2 Competent Person will have a valid C-5 Supervisor/Competent Person for Deleading of Industrial Structures
No longer any allowance for Certified Industrial Hygienist (CIH)
Professional Engineer (PE) required to certify loading on bridge structure if weight of attached containment weighs 1000 pounds or more
50
SSPC = Steel Structures Painting CouncilNow the Society for Protective Coatings @ www.sspc.org
26
Surface Prep Section 411.04
This section outlines Nine methods for Preparing Surfaces for Coating.
The most common issues and methods are:
Method 7 Low-pressure Washing [411.04(a)7]: Lead is relatively insoluble in Wash Water, and the resulting material does not normally contain sufficient lead to require disposal as HazWaste.
- disposal in local POTW or equivalent
- should not dispose of wash water by pouring it in drums of paint waste
Note for Methods 5 and 9, Abrasive Blast Cleaning requires Recyclable Abrasives (e.g. steel shot). However, if surface preparation involves less than 1000 square feet per structure, Expendable Abrasives may be used [411.04(a)5 and (a)9]
51
SSPC / NACE Surface Preparation Guides: 411.04(a)
52
27
Environmental Protection Plan (EPP): Section 411.09
Project Number & Location
Detailed site-specific Environmental Protection Plan [411.09(a)]
Organization of Prime Contractor and/or Subcontractors
Brief Description of Scope of Work
Environmental Controls for Capture & Containment of Wastes
Waste Storage Area / Testing / Disposal
Contractor and Worker Certifications
Applicable to any bridge project with painted steel that involves Demolition or Disturbance of Paint – not just for Bridge Painting Projects !
53
Environmental Plan Review
EPP submitted by Contractor for review no less than Three Weeks prior to Commencement of Work [411.09(a)]
Forward EPP to HazMat Manager along with Containment Drawings, Health & Safety Plan, other Supporting Documentation
Central Office will review H&S Plan
I will Review EPP as quickly as possible, and return with Form C-6
Typical Turn-Around Time is 3-5 days
A Typical Contractor will require 2-3 iterations before an Acceptable EPP is Submitted. For multiple bridge projects, submit one plan as early as possible, then once approved, it can be used as a template for the remaining structures.
Pay Item [411.11] complete when EPP [411.09] and H&S Plan [411.10] have been reviewed and found complete [411.09(a) & 411.10(a)]
54
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Form C-6, Page 1: Project Engineer & Inspector55
Form C-6, Page 2: HazMat Manager56
29
Environmental Containment: 411.09(a)
“The Environmental Protection Plan shall include controls for capture, containment, collection, air monitoring, storage, and transportation of waste materials generated by the work.”
- A Containment Structure typically used for capture, containment
& collection of waste materials
- Hand Tool with a vacuum shroud may suffice for spot work
“The Contractor shall use the most effective method possible for capture, collection, containment, and transportation operations.”
- Impossible to collect every little speck of paint
- However, the containment must be as effective as possible
“Emissions will not be permitted outside the containment system. TheContractor shall immediately correct any visual emissions outside thecontainment system to comply with emission standards.”
57
Containment Structures
58
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Containment Structures
59
Containment Structures
60
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Loss of Containment
61
Proper Labeling of Waste Containers: Section 411.09(c)
62
32
Proper Storage of Waste Containers: Section 411.09(c)
63
Proper or Improper Storage of Waste?64
33
Provisional EPA Identification Number: 411.09(d)3
Contractor obtains Interim ID#’s from DEQ
Construction Projects have sufficient room for StorageMay use an off-site Storage Area within ~5 miles of Bridge
65
Uniform Hazardous Waste Manifest
Transport within 60 days of completion of painting
411.09(d)4
Disposal with 90 days of generation – Transport usually takes 3-5 days
Must receive Signed Copy within 45 days of Shipment; Begin Inquiry 35 days after
Shipment if Manifest not Received
Required Documentation
for Disposal Pay Item
411.11
66
34
End of Part 4: Bridge Coatings / Lead-Based Paint (LBP)
67
Questions or Comments??
Part 5: Demolition68
35
Section 413 – Dismantling and Removing Existing Structures or Removing Portions of Existing Structures
413.02(a)1 – Retention of Structure by Contractor• Contractor Responsible for Handling Steel and/or Wastes
413.02(c) – Environmental Protection Plan (EPP) required• EPP requirements in accordance with Section 411.09
• Submission of EPP NOT Required if paint disturbance < 100 square feet
Material Disposal: In accordance with 411.09(c)&(d)• Solid Waste – 411.09(d)1 [trash] and d(2) [liquid waste]
Disposal Facility ID - name, address, etc.
• Hazardous Waste 411.09(d)3Hazardous Waste Characterization – Testing or Generator Knowledge
Hazardous Waste Manifests – signed copy within 45 days
69
413.02(c) – Environmental Protection Plan Required
“Environmental protection shall be in accordance with Section 411.09except the Department will not require the Contractor to submit andimplement an environmental protection plan … for work involving theremoval of 100 square feet or less of protective coating from a Type Bstructure. However, the Contractor shall comply with appropriate local,state, and federal codes and regulations and shall employ appropriatemeasures to prevent the release of hazardous materials into theenvironment. Determination of the total square footage … shall notinclude … removal of bolts.”
Key Points:
ONLY the submission of a written EPP is waived
ALL other requirements apply
Paint Disturbance from Simple Unbolting is Not Counted toward total
- Suggest contractor provide calculations for Department review
70
36
Environmental Requirements if 100 ft2 or less of Coating is Affected
Contractor should provide Written Documentation for Cumulativesize of area to be Disturbed
Waste Material (paint, rust, scale, etc.) must be collected and contained on the project site
Contractor must comply with applicable waste transport, storage & disposal requirements
Although EPP is not required, Contractor must comply with all applicable laws and regulations during bridge demolition and/or repair, Sections 411, 413, & 107.16
71
Handling of Bridge Components
72
Paint Chips incorporated into soil can have sufficient Lead
to require handling as a D008 Hazardous Waste
37
73
74
http://www.doli.virginia.gov/leadasbestos/leadasbestos_forms.html
38
End of Part 5: Demolition
75
Questions or Comments??
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Section�3�–�Facility�Owner�Information���
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Section�4�–�Asbestos�Removal�Contractor�Information (complete�ALL of�Section�4,�if�this�is�a�Removal/Abatement Operation)Name:� ������� License�#:� �
Federal�Employer�ID�#:� �
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Contact:�������������������������������������������������������������������������������������������������������������������������� Telephone�#:��������
Section�5���Demolition�Contractor�Information�(complete�ALL of�Section�5,�if�this�is�a�Demolition�Operation)�Name:� �������������������� �
Address:� �
City:� � State:� � Zip:���
Contact:����������������������������������������� � Telephone�#:� �
Section�6���Facility�Information���
Building�Name:� ������������ �
Address:� �
City:� �������������� State:��VA� Zip:� �
Site�Location:�(crawlspace,�room#,�etc)����� �
Building�Size:�������������������� � #�of�Floors:�� Age�in�Years:���
Present�Use:����� Prior�Use:���������Bridge� Military/�Federal� School/College� Bridge� Military/�Federal� School/College�Commercial� Office� Ship/Maritime� Commercial� Office� Ship/Maritime�Church/Place�of�Worship� Public�Building� Vacant� Church/Place�of�Worship� Public�Building� Vacant�Industrial/Manufacturing� Residential� Other:�Click�here.�� Industrial/Manufacturing� Residential� Other:�Click�here.��
Section�7��Work�Schedules������������������������������������������������������������������� � Check�if�this�section�is�being�revised�from�a�previous�submittalRemoval/Abatement�(Submit�notification�20�calendar�days�prior�to�start)���������������������������������������������������Start:���������������������������������������������Finish:���
Days�of�Operation:�� ����� Mon.�Fri.������ Sat.� Sun.��� �� ������������������ ���
Other:�� Mon� Tues�� Wed�� Thu�� Fri�� Sat�� Sun��Hours�of�Operation�Start)�����___________����AM��Hours�of�Operation(Finish)���___________����PM���Comments:�__________________________________________�
Demolition��(Submit�notification�10�working�days�prior�to�start)�������������������������������������������������Start:����������������������������������������������Finish:���
Accounting/Finance�Use�Only
FINANCE�ID:�_____________________________�EMERGENCY�WAIVER�REQUEST�
��������������Approved�by:��___________________________�
�������������Date:������������������___________________________�
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IS�ASBESTOS�PRESENT?��� �Yes������� No����� To�be�removed�prior�to�demolitionSection�8���ACM�To�Be�Removed������������������������������������������������������� Check�if�this�section�is�being�revised�from�a�previous�submittalIndicate�the�amount�of��ACM�(Asbestos�Containing�Material)��to�be�removed,�encapsulated,�enclosed,�etc.�
Indicate�the�amount�and�type�(floor�tile,�roofing,�etc.)�of�non�friable�Category�I�and/or�Category�II�ACM�that�will�not�be�removed�prior�to�demolition.�(indicate�whether�ln�ft,�sq�ft,�or�cu�ft.)�
Description� Amount�
Pipe�(linear�feet)� � Description� Amount� �Units�Surface�Area�(square�feet)� � Category�I� � �Facility�Component�(cubic�feet)� � Category�II� � �
Section�9���Work�Procedures�������������������������������������������������������������������Check�if�this�section�is�being�revised�from�a�previous�submittal� �Procedure,�including�analytical�method,�if�appropriate,�used�to�detect�the�presence�of�asbestos:������ PLM����� TEM������ Presumed�ACM�Inspector:�����������������������������������������������������������������������������������������������License#:��Asbestos�Removal�or�Demolition�Work�Practices��to�be�Used��(Check�all�that�apply)�:�
Asbestos�Removal� Demolition��Containment� �Remove�Intact� Bulldozer/Loader����������������� Wrecking�Ball��Wet�Methods� �Rotating�Blade�Roof�Cutter� Hand/Manual�Methods������ Implode/Explode��Negative�Pressure� �Mechanical�Chipping� Live�Burn�Training��Glove�Bag� �Component�Removal� Other���Other���Description�of�work�practices�and�engineering�controls�to�be�used�to�prevent�emissions�of�asbestos�if�procedures�other�than�approved�
methods�will�be�used:����Description�of�procedures�to�be�followed�in�the�event�that�unexpected�asbestos�is�found�or�previously�nonfriable�asbestos�material�becomes�crumbled,�pulverized,�or�reduced�to�powder:���
Section�10���Emergency�Waiver�Request��Check�the�Emergency�Waiver�Request�box�on�page�1�and�attach�a�letter�from�the�facility�owner�explaining�the�nature�of�the�emergency.����Date�and�Hour�of�Emergency:��________________________���Time:��______________________���Description�of�Sudden,�unexpected�event:��____________________________________________________________________________________��Explanation�of�how�the�event�caused�unsafe�conditions�or�would�cause�equipment�damage:��____________________________________________��Section�11���Demolition�Ordered�by�A�Government�AgencyName:��� Title:Authority:��Date�Ordered:�� Date�Demolition�Ordered�to�Begin:��Section�12��Transporters�and�Waste�Disposal�Site������������������������ � ��Check�if�this�section�is�being�revised�from�a�previous�submittal�Transporter�#1:��Address:��City:�� State:�� Zip:��Contact:�� Telephone:���Transporter�#2:��Address:��City:�� State:��� Zip:���Contact:�� Telephone:���Waste�Disposal�Site:��Address:��City:�� State:�� Zip:��Contact:�� Telephone:�� Landfill�permit#:��
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Section�13���Fees�The�asbestos�project�permit�fee,�when�applicable,�MUST�be�submitted�with�the�completed�project�notification�form.�The�fee�shall�be�in�accordance�with�the�following�schedule�unless�a�blanket�notification�(as�described�below)�is�granted.��If�the�amount�of�the�asbestos�is�reported�in�both�linear�feet�and�square�feet�the�amounts�will�be�added�and�treated�as�if�the�total�were�all�in�square�feet.���The�asbestos�project�permit�fee�may�be�paid�by�check,�money�order,�or�credit�card�(VISA�and�MASTERCARD�only).�Make�checks�payable�to�the�TREARSURER�OF�VIRGINIA.�If�payment�is�made�by�credit�card,�complete�the�Credit�Card�Authorization�Form�and�submit�with�the�application.���
��$50���10�linear�feet�or�10�square�feet�up�to�and�including�260�linear�feet�or�160�square�feet��
��$160���261�linear�feet�or�161�square�feet�up�to�and�including�2600�linear�feet�1600�square�feet��
��$470���2601�linear�feet�or�1601�square�feet�or�more.��
�$15����amended�notification��
��Blanket�notification���0.5%�of�the�contract�price�or�$470�whichever�is�greater.�A�blanket�notification,�valid�for�a�period�of�one�year,�may�be�granted�to�a�contractor�who�enters�into�a�contract�for�asbestos�removal�or�encapsulation�on�a�specific�site�which�is�expected�to�last�one�year.�Include�of�copy�of�the�contract�with�the�notification.��Contract�price�$�Click�here.���X�.005�(.5%)�=�$�Click�here.��
�$0�–Residential�buildings�with�four�or�fewer�units�and�are�currently�in�use�or�intended�for�use�only�for�residential�purposes�are�exempt�from�asbestos�project�permit�fees.���
�$0�–�An�asbestos�project�permit�fee�is�not�required�for�asbestos�removal�at�Federal�Government�properties,�military�installations,�ships,�maritime�and�demolition�operations.��Enter�the�total�fee�due�for�the�project:�$�����Section�14���Certification������������������������������������������������������������������������� Check�if�this�section�is�being�revised�from�a�previous�submittalI�certify�that�an�individual�trained�in�the�provisions�of�the�NESHAP�regulations�will�be�on�site�during�the�demolition�or�renovation�and�evidence�that�the�required�training�has�been�accomplished�by�this�person�will�be�available�at�the�project�site�for�inspection.�(40�CFR�Part�61,�Subpart�M,�required�after�November�20,�1991)��
Supervisor:� � License�#:� �� � Project�Monitor:� � License�#:� �
Project�Designer:� � License�#:� �Laboratory:� � License�#:� �
� � � �I�certify�that�the�information�submitted�is�accurate�to�the�best�of�my�knowledge�and�that�accredited�persons�are�being�used�on�this�project.�Name:����Signature:��____________________________________�
Title:����Date:�___________________�
�Please�make�sure�that�all�required�fields�have�been�completed.�Incomplete�notifications�will�not�be�processed.�
Section�15�Submission�Address�notifications�as�described�below:Original�notifications�must�be�sent�by�FAX,�certified�mail,�or�hand�delivered�to�the�department�at�the�address�below.���DEPARTMENT�OF�LABOR�AND�INDUSTRY��Attention:�Accounting/Finance�Main�Street�Centre�600�East�Main�Street,�Suite�207�RICHMOND,�VA.�23219�FAX�(804)�371�7634�
The�US�EPA�must�also�be�notified�for�demolition�operations�and�renovation�operations�when�the�amount�of�RACM�disturbed�is�at�least�160�sq.�ft./260�ln.�ft/35�cu.�ft.��This�form�may�be�used�to�fulfill�this�requirement.�Notifications�required�by�the�US�EPA�must�be�mailed�to�the�address�below:���ASBESTOS�COORDINATOR�USEPA�REGION�III�MAIL�CODE�3LC62�1650�ARCH�STREET�PHILADELPHIA,�PA�19103�2029��
�For�additional�information�concerning�the�completion�of�this�form,�please�contact�the�Virginia�Department�of�Labor�and�Industry�Lead�and�Asbestos�Program�at�(804)�786�9865�or�visit�our�web�site�at�http://www.doli.virginia.gov/leadasbestos/leadasbestos_intro.html���
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COMMONWEALTH�OF�VIRGINIA� � � � � � DEPARTMENT�OF�LABOR�AND�INDUSTRY�
CREDIT�CARD�AUTHORIZATION�FORM�Non�Fillable�Form��This� information� is� confidential.� � This� form�will� only� be� kept� by� the� Department� of� Labor� and� Industry� Finance�Department.� � Please� print,� complete� and� submit� with� applicable� documentation.� � Incomplete� forms� may� be�returned�for�completion,�which�will�delay�processing.� � � � � � (Please�Print�Legibly)�
Company�Name:__________________________________________________________________�
Federal�Employer�Identification�Number:______________________________________________�
Name�Listed�on�Credit�Card:_________________________________________________________�
Cardholder�Billing�Address:__________________________________________________________�
City:______________________________��� State:________�� ��Zip�Code:__________________�
Contact�Daytime�Phone�Number:�(���������)�________�__________�
Reference/Invoice/Inspection�Number�(if�applicable)___________________________(9�digits)�
Credit�Card�Type:��_____Visa� _____MasterCard��(Only�Check�One)�
Credit�Card�#�________________________________� �
Expiration�Date:�_____/______(Month/Year)����� � Payment�Amount:________________�
Cardholder�Signature�_________________________������� Date:___________________________�I�certify�that�I�am�the�authorized�holder�and�signer�of�the�credit�card�referenced�above.��I�certify�that�all�information�above�is�complete�and�accurate.�I�hereby�authorize�the�Department�of�Labor�and�Industry�to�process�payment�for�all�charges�as�indicated�above.��If�additional�charges�are�going�to�be�authorized,�a�new�form�will�have�to�be�completed.�Mail�or�Fax�Completed�Form�to:�Department�of�Labor�and�Industry� � � � 600�East�Main�Street,�Suite�207�Attention:�Accounting�/�Finance� � � � � Richmond,�VA�23219� � � � � �Fax:�804�371�7634� � � � � � Payment�Questions:�(804)786�9876�FINANCE�USE�ONLY�PROGRAM:�� � � � � � � FINANCE�ID�#� � � � � � �
___ASBESTOS/LEAD�___BOILER� � � � � � � � � � � � �___LABOR�LAW�___APPRENTICESHIP� � � � � � � DATE:______________________________� �___CONFERENCE�___VOSH� � � � � � � � PROCESSED�BY:_______________________�___FOIA�___ADMINISTRATION�___OTHER �