Attachment J-1d Appendix D.pdf

ASBESTOS OPERATIONS AND MAINTENANCE (O&M) PLAN

COLORADO SPRINGS ATCT

(COS ATCT)

COLORADO SPRINGS, COLORADO

Prepared For:

Federal Aviation Administration Western Service Area Denver District Office

Colorado Springs, Colorado SSC

Prepared By: Thomas Nash

APPENDIX D

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EXECUTIVE SUMMARY

An asbestos survey following AHERA protocols was conducted on February 16, 1995 by Research Management Consultants INC. AHERA inspections focus on the identification of asbestos containing building materials (ACBM) such as surfacing materials, thermal system insulation, and miscellaneous materials. Sampling was performed in a non-destructive manner.

This means that materials behind walls, inside doors, etc., were not sampled and must be assumed to contain asbestos until proven otherwise. The full report of the survey is on file with the site SSC Manager and the SECM.

Although ACM can be removed from a facility, when appropriate precautions are taken, both OSHA and EPA recommend implementation of a proactive O&M program for managing asbestos in place. The program is to be accomplished through notification; surveillance; work practice and controls; recordkeeping; worker protection and training. This O&M plan follows the guidelines set out in FAA Order 1050.20A to accomplish these goals and to continue to be in compliance.

This plan, written by Thomas Nash Occupational Safety and Health Analyst with Leidos Corp, will be submitted to the local District Safety and Environmental Compliance Manager, who will review and provide to the local facility manager and facility asbestos coordinator (FAC), as applicable. This O&M plan has some limitations to how it was written. In the report, the inspectors left out some necessary details, like color, of the materials. Therefore, the report is modeled to follow closely with the ACM report, if there are any questions about materials, including colors of material, may contain asbestos, then it is recommended to have the materials in question be sampled for clarification.

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The following materials were found to either contain asbestos or presumed:

Room Location Material Description ACM

Type Sample

Location Total

Asbestos Throughout building Cream 1’ x 1’ floor tile Chrysotile Floor 5%

Throughout building

Mastic associated with cream 1’ x 1’ floor tile Chrysotile Floor 20%

Throughout building Pipe insulation paint

Chrysotile/ Tremolite/ Actinolite

Pipes 15%

Throughout building Fire Doors PACM Doors PACM

Base building Black 1’ x 1’ floor tile Chrysotile Floor 6%

Base building Mastic associated with black 1’ x 1’ floor tile Chrysotile Floor 20%

Base building Penetration putty Chrysotile Pipe Penetrations 5%

Base building Roofing materials PACM Roof PACM

Link roof Roofing materials PACM Roof PACM

Eighth floor Elevator brake shoes PACM Elevator Machine Room PACM

Ninth Floor (CAB) Sink undercoat Chrysotile CAB Sink 10%

Ninth Floor (CAB) Roof mastic Chrysotile Roof 40%

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TABLE OF CONTENTS

EXECUTIVE SUMMARY

I. INTRODUCTION:

II. PURPOSE:

III. DEFINITIONS:

IV. ASBESTOS LOCATIONS:

V. EMPLOYEE TRAINING:

VI. NOTIFICATION:

VII. WORK CONTROL SYSTEM

VIII. RELEASE ACTIONS:

IX. FACILITY INSPECTION:

X. RECORDKEEPING:

XI. JOB SITE CONTROLS FOR WORK INVOLVING ACM:

XII. SAFE WORK PRACTICES:

XIII. WORKER PROTECTION:

ATTACHMENTS

Attachment A: Asbestos Survey Data and Facility Drawing Attachment B: ACM Inspection Form Attachment C: FAA Asbestos Info

I. INTRODUCTION:

A site-specific Operations and Maintenance (O&M) program is required for each facility that contains known asbestos containing material (ACM), or material suspected or assumed to contain asbestos (PACM). Asbestos containing material is defined as any material containing more than >1% asbestos. Suspected building materials must be assumed to contain asbestos, and shall be treated as ACM until the material has been tested and determined not to contain asbestos.

II. PURPOSE:

The primary objective of this O&M plan is to control building occupant and employee exposure to asbestos fibers. In addition, the procedures in this plan attempt to minimize any potential hazard posed by ACM/presumed ACM (PACM) during cleaning, maintenance, and general operation activities.

This plan applies to employees, tenants, other building occupants, and contractors.

APPENDIX D

Charles A Andrews Highlight

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III. DEFINITIONS:

A. Asbestos. Includes chrysotile, amosite, crocidolite, tremolite asbestos, anthophylite asbestos, actinolite asbestos, and any of these minerals that have been chemically treated or altered.

B. Asbestos Containing Material (ACM). Any material or product that contains more than 1% asbestos.

C. Category I Non-friable ACM. Material such as packing, gaskets, resilient floor covering, and asphalt roofing products containing more than 1% asbestos.

D. Category II Non-friable ACM. Any material containing more than 1% asbestos that is not category I non-friable ACM, and that, when dry, cannot be crumbled, pulverized or reduced to powder by hand pressure. Category II ACM includes, but is not limited to:

1. Asbestos cement siding and shingles,

2. Transite panel boards, and

3. Asbestos cement pipe (asbestos cement pipe may not be limited to buildings).

E. Class I Asbestos Operations. Activities involving the removal of TSI and surfacing

ACM/PACM.

F. Class II Asbestos Operations. Activities involving the removal of ACM which is not TSI or surfacing material. This includes, but is not limited to, the removal of asbestos-containing wallboard, floor tile and sheeting, roofing and siding shingles, and construction mastics.

G. Class III Asbestos Operations. Activities involving repair and maintenance operations, where ACM including TSI and surfacing ACM/PACM is likely to be disturbed.

H. Class IV Asbestos Operations. Maintenance and custodial activities during which employees contact but do not disturb ACM/PACM and activities to clean up dust, waste, and debris resulting from Class I, II, and III activities.

I. Friable ACM. Any material containing more than 1% asbestos that, when dry, may be crumbled, pulverized, or reduced to powder by hand pressure.

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J. High-Efficiency Particulate Air (HEPA) Filter. A filter capable of trapping and retaining at least 99.97% of monodispersed particles of 0.3 micrometers or larger in diameter.

K. Permissible Exposure Limit. OSHA PELs are worker exposures limits regulating the amount or concentration of a substance in air that shall not be exceeded:

1. airborne concentration of asbestos of 0.1 fibers per cubic centimeter of air (f/cc) as an eight-hour time weighted average (TWA).

2. airborne concentration of asbestos of 1.0 f/cc as averaged over a sampling period of 30 minutes (Excursion Limit).

L. Presumed Asbestos Containing Material (PACM). Thermal System Insulation (TSI) and surfacing material found in buildings constructed before 1981 and floor tile installed in buildings through 1981 may contain asbestos. Although it is unlikely, some flooring installed after 1981 may contain asbestos. Until sampling demonstrates that the material has 1% or less asbestos, we consider these materials

PACM.

M. Regulated Asbestos Containing Material (RACM). RACM includes:

1. Friable asbestos material;

2. Category I non-friable ACM that has become friable, or has been subjected to sanding, grinding, cutting, or abrading; and

3. Category II non-friable ACM that has a high probability of becoming crumbled, pulverized, or reduced to powder during the course of demolition or renovation operations.

N. Vinyl Asbestos Floor Tile. When vinyl floor tile, and in some cases its mastic, contains more than 1% asbestos, it must be handled as ACM.

IV. ASBESTOS LOCATIONS:

Actual survey results have confirmed the presence of ACM in buildings and locations listed in the asbestos inventory. The asbestos in these materials does not constitute a health hazard if left undisturbed. See Attachment A.

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V. EMPLOYEE TRAINING:

All maintenance, custodial, and other employees who may disturb asbestos during their normal job duties must complete a minimum of 2 hours of asbestos awareness training BEFORE they begin duties where there is a potential for contact. This training is taken annually.

Awareness training should include such topics as:

• Background information on asbestos,

• Health effects of asbestos,

• Worker protection programs,

• Locations of ACM and PACM at the facility,

• Recognition of ACM and PACM damage and deterioration,

• The O&M plan for the facility, and

• Proper response to fiber release episodes.

An asbestos awareness training course provides certificates of completion and meet the requirements of OSHA 29 CFR 1910.1001(j)(7)(iv). The FAA offers this training to all employees in a facility that contains ACM.

VI. NOTIFICATION:

The Facility Manager/FAC must:

• Notify the following personnel of the presence, location, and physical condition of the ACM, and stress the need to avoid disturbing the material:

- Building employees,

- Tenants who will occupy the areas,

- Contractors bidding work in the building, and

- Contractors working in adjacent rooms.

• Distribute written notices, post signs or labels on ACM where employees can see them, and make the O&M plan available to anyone who might work on or disturb the ACM. All warning signs and labels posted on areas containing asbestos must comply with OSHA regulations in 29 CFR 1910.1001(j) (3) and (4).

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• Make sure contractors who may come in contact with ACM or PACM are aware of this material by having them review the O&M plan and sign the Contractor Notification Form for Asbestos, Attachment C of this document.

VII. WORK CONTROL SYSTEM

The purpose of the Asbestos Work Control System is to control the activities, facility personnel, and work practices that may impact the asbestos within the facility. Personnel initiating the work must request, receive approval for, and post an asbestos work permit prior to all activities that may contact or disturb the asbestos. The FAC shall review and approve all work permits involving asbestos operations.

In addition to the asbestos work permit, the requirements of the latest edition of Order 3900.57A, FAA Preconstruction and Maintenance Project Safety and Health Checklist (Form 3900-18) and/or Pre-Maintenance EOSH Checklist (Form 3900-20), shall be followed.

Work Permits (FAA WP form 1050-6A and 1050-13A)

Work Permits shall be required whenever there is a potential to disturb any asbestos containing materials. The FAC shall issue those permits.

Examples of work that requires a permit are:

• Drilling.

• Sanding, scraping.

• Carpet replacement.

• Hammer drilling.

• Cable pulling.

• Any wall, ceiling tile or floor tile removal.

• Construction, modifications and renovation of the facility.

• Any "active work" in regulated areas.

• Removal and installation of ceiling electrical fixtures in the vicinity of ceilings that contain ACM or PACM.

• Work in or near areas where TSI may be disturbed.

Air samples may be taken during some of these activities, if directed by the FAC/SECM. If possible, tests will be run prior to those activities to determine the expected airborne level of asbestos and procedures and protection will be based upon the results of these samples.

Work will be halted if there are indications that asbestos is becoming airborne and migrating outside the asbestos containment controls. Work will remain stopped until measures are implemented to contain/reduce the airborne concentrations to acceptable levels.

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VIII. RELEASE ACTIONS:

Asbestos response actions at this facility will be performed by either properly trained FAA employees (Class III and IV only), or certified and approved contractors. One or more of these response actions may be required to safely manage and dispose of ACM/PACM. Response actions include abatement, encapsulation, enclosure, repair, and operations and maintenance (O&M). The type of response action may be determined by any of the following: condition of the ACM/PACM, proximity to occupied areas, potential for disturbance, and/or planned renovations or demolition activities. When a potential health hazard to building occupants exists due to the presence of damaged or friable ACM/PACM, appropriate response actions shall be initiated. Whenever an accidental release occurs, FAA employees may be used to contain the area to prevent the spread of contamination to nearby work areas until such time as a licensed contractor can be obtained.

A. Emergency Procedures

1. Emergency asbestos releases include the following:

a) Release during abatement or work involving ACM.

b) Unplanned release of suspected asbestos fiber due to causes other than construction or repairs (follow steps outlined below).

2. Employee Response

a) Any FAA employee who suspects that an ACM release has occurred shall:

(1) Vacate the area, isolate the disturbed ACM, shut off HVAC system supplying/returning from the affect area (if possible) and immediately notify their supervisor.

(2) Call the SECM and SSC manager. If they are not on duty, NAS Operations should be notified. The NAS Operations will then contact the people listed above.

3. SECM Response

a) The SECM with the support of the SSC Manager shall:

(1) Evaluate the emergency situation and develop hazard minimization procedures.

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(2) Contact other groups/representatives such as the Unions and SSC Manager.

(3) Notify WSA P & R Environmental PIM within (two hours) from the time of the incident and provide the following information:

(a) Date of the incident

(b) Time the problem occurred or was discovered

(c) Nature of the problem and actions taken

(d) Names of persons contacted

(e) Name of person reporting the incident.

(4) Facilitate air monitoring, which shall be initiated and continued until the results indicate that airborne concentrations have returned to baseline/background levels.

(5) Assess the impact that the incident will have on NAS and other affected operations. Decisions and clean-up activities will be based upon this impact.

(6) There may be a need to develop primary and secondary options in response to the emergency situation if there is a potential impact on the

NAS.

(a) Primary Response Options:

Isolate and seal off the area, if possible. If this is not possible or practical, the ACM should he isolated to prevent migration to other areas.

(b) Secondary Response Options

A certified asbestos contractor should be contacted to clean up the release. Engineering controls should be considered if immediate action is required and time permits.

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(c) Review Options and Develop Recommendations

Based upon the situation and available resources, a recommended course of corrective action shall be developed from the available options and presented to the SSC Manager for review and approval. This selected course of action shall place priorities on employee protection and minimizing NAS impact.

(d) Present the Recommendations to the SSC Manager

The SSC Manager or designated representative shall have the final decision on emergency actions. If the SSC Manager or designated representative is not available, the SECM shall have the decision-making authority.

(e) Implement the Decision

The SECM with the support of the on-site Industrial Hygienist, O&M trained personnel, and other supporting personnel shall implement the decision made by the SSC Manager.

B. Emergency Response Evaluation

The persons involved in the emergency response shall meet as soon as possible after the emergency is corrected to discuss and evaluate the actions taken and to make recommendations to improve emergency response performance in the future.

IX. FACILITY INSPECTION:

A. Periodic Surveillance A visual reinspection of all known or presumed ACM in the facility shall be conducted at least every three years by the FAC or another employee designated by the FAC and who has received at least 2 hours of awareness training.

The reinspection shall be designed to detect damage to, or deterioration of, the ACM and to facilitate any corrective actions needed (Attachment B). Personnel conducting this surveillance should note, assess, and document all changes in condition of known or assumed ACM in the facility since the last inspection. This will be documented using the Asbestos Reinspection Summary Form which can be found in the SSC Asbestos management plan.

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X. RECORDKEEPING:

Facility Managers must ensure that the employees retain all facility asbestos management documents, including:

• Copies of Asbestos Hazard Emergency Response Act (AHERA) inspection and assessment reports;

• Written O&M plan;

• Periodic ACM/PACM visual inspection records;

• Awareness training records; and

• Changes to location, condition, or quantity of the ACM/PACM.

XI. JOB SITE CONTROLS FOR WORK INVOLVING ACM:

Whenever maintenance, custodial, or other employees perform work in areas where ACM or PACM is present, they must use appropriate work practices and protective measures to minimize the potential to disturb the ACM/PACM.

This includes:

• Use of wet methods (such as applying water to ACM with a low pressure sprayer);

• Use of mini-enclosures;

• Area isolation;

• Avoidance of certain activities such as sawing, sanding, or drilling around ACM/PACM.

XII. SAFE WORK PRACTICES:

It is important to minimize the disturbance of ACM and the subsequent release of asbestos fibers.

You can accomplish this by staying out of physical contact with materials that contain, or are presumed to contain, asbestos.

All personnel at this facility must observe the following work practices to avoid or minimize fiber release during activities that may affect ACM/PACM:

• Do not drill holes into material containing asbestos;

• Do not hang pictures, signs (except asbestos warning signs), clothing, plants, or any other articles on structures covered with materials containing asbestos;

• Do not sand, saw, or grind floor tiles, hard board panels, or other materials that may contain asbestos;

• Do not damage materials containing asbestos while moving furniture or other objects;

• Do not install curtains, drapes, or dividers in a way that will damage materials containing asbestos;

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• Do not dust floors, ceilings, moldings, or other surfaces with a dry brush or sweep with a broom in an environment containing asbestos;

• Do not use an ordinary vacuum to clean up debris containing asbestos;

• Do not remove ceiling tiles below materials containing asbestos without wearing proper respiratory protection, clearing the area of other people, and observing asbestos waste disposal procedures;

• Do not remove ventilation system filters in a dry state; and

• Do not shake ventilation system filters.

XIII. WORKER PROTECTION:

Service employees must not participate in asbestos abatement activities unless they are in full compliance with State AHERA certification and licensing standards and follow OSHA and EPA requirements and the requirements in FAA Order 3900.19, and FAA Order 1050.20. In most instances, worker protection will be described in the employee Job Hazard Analysis.

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Attachment A - Asbestos Survey Data and Facility Drawing

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Attachment B - Asbestos Inspection Form

Asbestos Inspection Form

Semi Annual Inspection

Date:

Inspector:

The most recent accredited AHERA inspection is used as a basis for this survey.

Asbestos Materials Unchanged Contact Damage Water Damage

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Y / N Y / N Y / N

Comments:

Action Taken:

Action Approved By: Date:

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Attachment C - FAA Asbestos Info

Environmental, Occupational Safety and Health (EOSH) Training Standard

Asbestos General Awareness Course Title Asbestos General Awareness Instructor Qualifications For Instructor Led Course: Authorized instructor, supervisor, or manager with:

Comprehensive EOSH experience and training FAA employees that are instructors must have completed Facility

Instructor Training (FIT) FAA Course 10501, or equivalent as determined by the Service Area OSH Requirements Manager.

Completed Asbestos Abatement Contractor/Supervisor Initial Training and annual refresher training.

For instructor led refresher course, Asbestos Abatement Contractor/Supervisor training certification is not required.

Training Method Qualified Vendor or State/Federal Training Class FAA-led Training Class (Site Specific) FAA68000201 On-Line eLMS Course FAA68000288. This course includes both online materials and site specific asbestos information provided at the employee’s facility.

(Refresher) FAA-led Training Class (Site Specific) FAA68000202 Target Audience All ATO employees

Annually for all ATO employees who work in facilities that have asbestos-containing materials (ACM) or presumed asbestos containing materials (PACM), both friable and non-friable.

All maintenance and custodial (janitorial) workers who will work in close proximity with ACM/PACM, but will not disturb it (i.e., Class IV asbestos operations)

Prerequisite None Regulatory Drivers 29 CFR 1926.1101, Asbestos

29 CFR 1910.1001, Asbestos 40 CFR Subpart E FAA Order 3900.19, Chapter 15, Asbestos Control Program FAA Order 1050.20, Airway Facilities Asbestos Control Bargaining Unit Agreements

Training Outcome Participants will be able to recognize building materials that may contain asbestos and how to work safely in these areas

Participants will be able to describe several asbestos health effects Length of Course 2-hour for initial

As needed to review site specific information for refresher Frequency of Training Initial training (within 60 days of assignment to a facility with

ACM/PACM

Annual refresher training (If annual refresher training lapses by more than 2 years from previous training, employee must re-take the initial course)

Course Media Options Stand-up instruction (i.e., instructor led) for initial FAA-led training and site specific portion of eLMS course eLMS On-line course Course Materials Instructor specified

Course critique/evaluation

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Course Content OSHA Standards Any State and/or local requirements* FAA Orders Background information on asbestos Health effects of asbestos Overview of asbestos regulations Location of ACM/PACM in the building* Precautions for working around ACM/PACM Facility specific asbestos plans* Name and phone number of the Facility Asbestos Coordinator*

Recordkeeping Record completion in eLMS under FAA68000201 Asbestos General Awareness (initial) (instructor led only)

Record completion in eLMS under FAA68000202 Asbestos General Awareness (refresher) (instructor led only)

Automatically recorded in eLMS under FAA68000288 Asbestos General Awareness (Initial) (On-line) upon successful completion of course and acknowledgment of site specific training

Note: For employees that service multiple locations please update the employee’s training folder with a list of the sites that the employee received site specific asbestos information

*These items are the required elements for completing the annual refresher, FAA68000202.

Note: The ATO has determined that all ATO employees will receive the initial asbestos general awareness training regardless if they work in facilities that are known or presumed to contain asbestos materials.

Annual refresher training, however, will only be required for employees who work in facilities with known or presumed asbestos containing materials.

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Environmental, Occupational Safety and Health (EOSH) Training Standard

Asbestos Operations and Maintenance

Program Manager: Cheryl Mazzella

(202) 385-6568

Cheryl.mazzella@faa.gov June 10, 2013

Course Title Asbestos Operations and Maintenance Instructor Qualifications

EPA or State accredited training providers authorized to conduct initial and refresher Asbestos Operations and Maintenance courses.

Link includes state approved training providers: For Asbestos Professionals | Asbestos | US EPA

Training Method Qualified Vendor or State/Federal Training Class Target Audience

Employees who perform Class III asbestos operations Employees who conduct response actions for minor fiber release episodes.

Prerequisite

FAA68000201 Asbestos General Awareness (Initial) or FAA68000288 Asbestos General Awareness (Initial) (On-line) or FAA68000202 Asbestos General Awareness (Refresher)

Regulatory Drivers

FAA Order 3900.19, Chapter 15, Asbestos Control Program FAA Order 1050.20A, Airway Facilities Asbestos Control 29 CFR 1926.1101, Asbestos 29 CFR 1910.1001, Asbestos Toxic Substances and Control Act, Title II 40 CFR Part 61

29 CFR 1910.134

40 CFR 763.92(a)(2)

Training Outcome

Participants will be qualified to work on any Class III & Class IV O&M operation and respond to minor fiber release episodes.

Length of Course Minimum 16 hours training, to include hands-on training Frequency of Training

Annual refresher training required for employees who perform O&M activities, minimum 2 hours Course Media Options Stand-up instruction (i.e., instructor led) Course Materials Vendor specified Course Content

Federal regulatory requirements and FAA orders Nature of operations that could result in exposure to asbestos and proper asbestos-related work practices Methods for recognizing ACM/PACM Proper methods of handling ACM/PACM, including labeling and waste disposal procedures Respirator purpose, use, care, limitations, and fit-testing Protective clothing use and handling The relationship between smoking and asbestos in producing lung cancer and contact information for smoking cessation programs Hands on exercises for techniques such as glove bag and HEPA vacuum use and maintenance Medical surveillance program requirements Proper worker decontamination procedures

Recordkeeping

Record completion in eLMS under FAA68000203 Asbestos Operations and Maintenance (initial) upon satisfactory completion and issuing of certificate

Record completion in eLMS under FAA68000204 Asbestos Operations and Maintenance (refresher) upon satisfactory completion and issuing of certificate

Student roster will be maintained by Vendor Course critique/evaluation will be maintained by Vendor Completed Exams will be maintained by Vendor

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WSA WP-3900.19C-12-ACP

WSA WP-JO1050.20B-ASB

November 12, 2014

WORK CONTROL SYSTEM

The WCS must be utilized for all construction, installation, renovation, demolition, maintenance or other projects that impact building materials at a facility. The WCS is intended to be utilized as a communication tool for management, field personnel, contractor personnel and facility occupants.

The forms contained in this Appendix must be considered prior to and completed during the planning stages for all projects at WSA facilities. Applicable plans and specifications must be included with the completed forms, which then must be submitted to the FAC. It will be the responsibility of the FAC to inform the project initiator if ACM, lead-based paint (LBP) or lead-containing coatings (LCC) are present at specific facility locations that will be impacted by project tasks.

This Appendix contains two forms. The Work Request Review form (WSA 1050.6B) must be completed and submitted to the FAC/SECM at least 30 days prior to the commencement of any project impacting building materials at a WSA facility. Part I of the form is completed by the project initiator, and Part II is signed by the FAC or SECM (based on class of work) and posted at the entrance to a facility prior to the commencement of the project.

These forms must also be utilized in conjunction with all applicable forms associated with FAA Order 3900.57A (See Appendix C).

Instructions for completion precede each blank and sample form.

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WSA WP-3900.19C-12-ACP

WSA WP-JO1050.20B-ASB

November 12, 2014 Work Request Review Form

Part I of this form is filled out by the project initiator and requires the identification of:

1.

2.

3.

4.

5.

Project Name

Project Location (include address, City, State and zip) Scope of Work (attach plans and specifications) Project Start Date

Expected Completion Date Company Performing Work

* Person Supervising Work *

Name and Title of Person Making Request

Part II of this form requires completion by the FAC. The following elements require completion:

1.

2.

3.

Work Request Number (provided by SECM).

If there is asbestos impact, a project ID number must be assigned Approval/Disapproval of Permit Request with status.

General Remarks

* If information regarding the company performing work, contractor supervising work, or FAA point of contact is not available when the form is initially filled out, the data can be provided to the FAC when it becomes available.

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WESTERN SERVICE AREA

WORK REQUEST REVIEW FORM

PART I – PROJECT INFORMATION

(To be Completed by Project Initiator)

NAME OF PROJECT:

PROJECT LOCATION:

SCOPE OF WORK: (Attach Plans and Specifications, Hazardous Materials Communication Plan and MSDS if

Hazardous Materials are to be used.)

PROJECT SCHEDULE: START DATE STOP DATE

WHO WILL BE PERFORMING THE WORK?

FAA PERSONNEL CONTRACTOR

IF CONTRACTOR, COMPANY NAME

NAME OF PERSON SUPERVISING WORK

IF FAA PERSONNEL ARE PERFORMING WORK, LIST NAMES BELOW:

IF CONTRACTOR PERSONNEL ARE PERFORMING WORK, LIST NAMES BELOW:

PRINTED NAME, TITLE, AND SIGNATURE OF PERSON MAKING REQUEST DATE

PART II – WORK REQUEST STATUS

(To be Completed by the FAC)

Work Request #:

Will there be impacts to LCC or LBP?

YES

NO

If yes, Project ID#:

Will hazardous materials be

If yes, HAZCOM Plan & SDS

Is Asbestos present at the facility?

If yes, Project ID#:

Status: APPROVED DISAPPROVED

See Attached Asbestos Survey Report Do not impact asbestos

See Attached Lead Survey Report Do not impact lead

Lead Survey has not been performed at this facility, all paint must be assumed LCC / LBP Additional Remarks:

SIGNATURE OF FAC OR SECM DATE

REVISED FAA FORM WSA 1050-6B

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WESTERN SERVICE AREA

HAZARDOUS MATERIALS WORK PERMIT

MUST BE POSTED AT WORK SITE

PART I – PROJECT INFORMATION

(To be Completed by Project Initiator)

PERMIT REQUESTED BY: DATE:

PHONE NUMBERS:

LOCATION OF WORK:

Building Name and #:

Street Address: City, State, Zip:

SCOPE OF WORK: (Attach Plans and Specifications, Hazardous Materials Communication Plan & MSDS if

Hazardous Materials are to be used.)

PROJECT SCHEDULE: Start Date Stop Date

PART II – HAZARDOUS MATERIALS

INFORMATION

ASBESTOS IMPACTS:

Quantity Of ACM To Be Disturbed (Linear/Square/Cubic Feet):

Impacts: Friable Non-Friable Classification: Demolition Renovation Routine Maintenance Emergency Response Engineering Controls: Glove Bag Mini Containment Full Containment Other

* Date of EPA Notification: Date Approval Received:

** Date of State Notification: Date Approval Received:

*NESHAP regulations, 40 CFR 61, requires notification to the EPA if disturbance of ACM exceeds 260 linear feet, 160 square feet, or 35 cubic feet during a project; OR at the time annual accumulation of disturbed ACM will exceed these quantities.

**Notification in accordance with appropriate State Regulations.

LEAD IMPACTS:

Lead-Containing Coating Lead-Based Paint OSHA Trigger Task Non-OSHA Trigger Task

HAZARD COMMUNICATION:

HAZCOM Plan Attached MSDS Attached HAZCOM/MSDS to be Provided by Initiator Incorporated to DO HAZCOM Program

REMARKS:

WORK PERMIT NUMBER:

(Provided by SECM)

PERMIT APPROVED BY:

TITLE:

PHONE:

This permit is issued with the understanding that those workers involved have received the appropriate training and all certifications, medical, and respiratory documentation has been reviewed and is current.

REVISED FAA Form WSA 1050.13B