Attch_7_Asbestos_Work_Permit.pdf

EASTERN SERVICE AREA ASBESTOS WORK PERMIT

1) Permit #

Part A - To be completed by Requestor:

2) Requested By: __________________________ 3) Organization:

4) Date Requested: __________________ 5) Phone Number:

6) Worksite: _______________________________ 7) Start Date: ____________________________

8) Room Name / Number: 9) Completion Date: ______________________

10) Affected Building Materials:Ceiling : Floor: Other (list):

11) Description of Work: (Give specific details of work activities on page 4 if necessary):

12) If in the process of this project, the scope of work _ changes, a new permit will need to be requested.

13) Requestor Signature:

14) Required FAC Response Date:Send to appropriate SSC with a cc: to SECM and SMO OL

Part B -To be completed by Facility Asbestos Coordinator (FAC)

15) Has a survey been performed for asbestos? . .

16) Is a survey scheduled: YES: NO: .

N/A (ACM free building):

If YES, indicate date scheduled:

17) Will this scope of work disturb asbestos? If YES indicate location and estimated amount(s):

NO: .18) Is there other asbestos in the area that could be potentially disturbed? YES:

If YES indicate location(s):

19) Does this project require Federal, State, or Local notification? YES: N/A: .

20) Is air monitoring required? YES: .

21) Check the following special requirements:

HVAC system modified: . HVAC system shutdown:

Critical barriers required: Lockout/tagout electrical equipment: .

22)Has contractor provided proper credentials (certificate, license, respirator training)?

YES: NO: N/A: To be reviewed with contract submittals: .

23) The required O&M Standard Operating Procedure(s) Task Number should be utilized to perform this project:

Task#:

This permit issued with the understanding that the project to be done is limited to the work described.

24) PERMIT APPROVED DENIED BY: Date: ___________________

25) If this work permit is denied state reason:

26) Facility Asbestos Coordinator Phone #:

Send signed copy to Project Engineer for inclusion into engineering package, to the SECM and to the SMO OL

POST IN PROMINENT LOCATION AT JOB SITE (by the person or group doing the work) Part C -To be completed by workers

27) ALL PROJECT WORKERS MUST SIGN BELOW CERTIFYING THAT THEY HAVE READ AND ARE

AWARE OF THE ABOVE INFORMATION:

YES: NO:

Wall:

Title:

NO:

NO:

If multiple task numbers are required: Task#: Task#: Task#:

8APPENDIX 8. ESA WORK PERMIT SYSTEM

• Project Control. The ESA Work Permit System should be utilized as a communication vehicle for management, engineers, technicians, facility personnel, and independent contractors.

o The policy of the FAA ESA Technical Operations Division is that all Districts and Engineering Services Groups will implement and follow the work permitting system procedure for all activities that may potentially impact an existing building material. Work permitting and/or survey related issues shall be addressed during the design of any project. It is the responsibility of the person and/or group (District Office, Engineering Services, etc.)

initiating the work to submit the work permit to the FAC and a copy to the SECM in the prescribed time frames, otherwise, the project may be delayed due to the review process involved.

o For asbestos abatement and O&M-related abatement projects implemented by Engineering Services or an Engineering Services contractor (TSSC), the work permit shall be submitted to the appropriate SSC, the respective SECM and/or FAC with a copy to the Engineering Services OL. The work permit shall be submitted with the Work Order/Engineering packages, or with the project documentation at the 90% review.

o For asbestos abatement projects the work permit shall be submitted at least 45 days prior to the start of the project to assure compliance with union notification requirements.

o For O&M-related abatement activities, the work permit shall be submitted at least 14 days prior to the start of the project.

o For emergency-related O&M abatement activities, where critical equipment requires repairing and/or replacing due to the failure or eminent failure of the equipment and where building materials are likely to be impacted. It is the responsibility of the person and/or group conducting the work to contact the FAC and/or SECM in order to determine the location of asbestos containing materials in reference to where the emergency work is to be performed. In the event of an emergency abatement activity, the work permit may be completed and submitted at the discretion of the FAC and/or SECM.

• ESA Work Permit Approval Process. It is the responsibility of the FAC and/or SECM to review the work permit;

determine if any known, presumed and/or assumed ACM could potentially be impacted by the work (reviewing the survey report and/or site visit); and deny or approve the work permit based on findings prior to the start of renovation/construction activities.

o The FAC will be the point of contact for all demolition, renovation, and/or O&M activities which may disturb known, presumed and/or assumed ACM. Upon receiving a request, the FAC will complete the ESA Work Permit form and will forward a copy of the approved or denied work permit to the person and/or group (District Office, Engineering Services, etc.) performing the work, to the SECM and to the Engineering Services OL for Engineering Services Projects. The original copy of the work permit will be retained and filed by the FAC.

o For Guidance to determine the appropriate SOP task number needed for air monitoring and special requirements, refer to the “Asbestos Containing Materials Action Flow Chart” in Appendix 15, Standard Operating Procedures.

• Tracking. Proper completion of the work permit allows for detailed tracking of each project with regard to FAA personnel and/or contractors involved, project location, type of work, scheduling, quantity of ACM disturbed, handling of debris, and appropriate notification procedures.

• Recordkeeping. As part of the ongoing record keeping process required by Federal, state, and local regulatory agencies, the work permit provides vital documentation unique to each ACM related project. The work permit specifies the personnel and/or contractors involved, project location, type, quantity, engineering control methods, and scheduling for each ACM project. This document becomes a permanent record detailing the specifics of each project and is the written authorization to proceed with the project.

6. Worksite - Name and location where the work is to take place.

7. Starts Date - The anticipated date work is to commence.

8. Room Name/Number - The room names and/or numbers where the work will take place.

9. Completion Date - The anticipated date of completion.

10. Affected Building Materials - List all building materials that will be impacted by the scope of work.

11. Description of Work - Describe in detail the work to be performed.

12. Change in scope of work - Must submit a new and revised work permit request.

13. Requester Signature - Must be signed by the individual requesting the work.

14. FAC Response Date – The date the work permit should be returned to the requestor.

Part B - to be completed by FAC

15. Facility Survey – Indicate whether the facility has been surveyed for asbestos containing material (ACM).

16. Facility Survey Schedule – Indicate whether the facility is scheduled for a survey for ACM. If a survey is scheduled, indicate the date.

17. Disturbance of ACM - Will the scope of work disturb any ACM? If so, indicate the location and the amount.

18. Unplanned Disturbance of ACM – Is there any other known ACM in the area that could possibly be impacted by the scope of work?

19. Notification - The amount of ACM to be impacted (or removed) may require Federal, state, or local notification.

20. Air Monitoring - Does the scope of work require air monitoring?

21. Special Requirements – If required, check tasks that need to be completed.

22. Contractor Submittals - The contractor must provide a submittal package for review (if required).

23. Required Sop’s to complete the Task – List the SOP(s) required to perform the requested task.

24. Permit Approved personnel is to circle whether work permit is approved or denied, and sign the form.

25. If the work permit is denied, state the reasons for denial.

26. Phone – FAC telephone number.

Part C - To be completed by workers

27. Worker Sign-in - Must be signed by all individuals associated with the scope of work contained in the work permit.

ESA WORK PERMIT INSTRUCTIONS

1. Work Permit Number - A unique number assigned by the FAC.

Part A - To be completed by Requestor

2. Requested By - Name of the individual requesting the work.

3. Organization - Name of the organization or company requesting the work.

4. Date requested - Date of original request.

5. Phone - Telephone number of the requester.

11) Description of Work: (Continued):

9.0.0.2.20101008.1.734229 Description of Work: (Give specific details of work activities on attached sheet if necessary: Asbestos floor tiles will need to be removed to facilitate removal and replacement of fire partitions and fire doors. The floor tiles have tested positive and the existing doors and caulking also contain asbestos and will need to be treated as such from abatement to disposal.