GZ_M23004_rpt_01.pdf

Hazardous Structural Materials Report Skipanon Bridge Key # M23004

OR 104 Spur, MP 4.62, Bridge #01400 Clatsop County

March 13, 2023

Prepared by:

Joe Fassio, R.G.

Oregon Department of Transportation Region 2 Technical Center 455 Airport Rd SE, Bldg. B Geo-Hydro-HazMat-Landscape Section Salem, OR 97301-5397

Key # M23004 Skipanon Bridge March 2023

Executive Summary The Oregon Department of Transportation (ODOT) Region 2 Hazardous Materials Group (HazMat) has conducted this Hazardous Structural Materials Report (HSMR) for the Skipanon Bridge Project, located at OR 104 Spur, MP 4.62, Clatsop County, Key # M23004. The purpose of this report is to document the survey of potentially hazardous structural materials on the Structure including asbestos and paint.

Based on the data presented herein, ODOT Region 2 HazMat recommends the following:

• No asbestos abatement work is required for the Project. Special Provision 00295 will be needed to document these results.

• Lead and chromium were found in painted elements in the work area. Special Provision 00296 will be required.

• Treated wood is present in the work area. Wood removed for the project will need to be treated as solid waste in accordance with 2021 Oregon Standard Specifications for Construction 00290.20(c)(3)(c)

If the project scope of work should change, or if site conditions are not as described, then all work should stop, and Region 2 HazMat should be contacted so that additional assessment can be conducted.

Skipanon Bridge March 2023

Table of Contents

1. Introduction

1.1. Project Description

1.2. Historical Data on Structure

2. Asbestos Survey

3. Paint Survey

4. Other Hazardous Materials

5. Recommendations

6. Limitations

7. Signatures

8. References

Attachments:

AHERA Certification(s) Figure 1 Project Area Map Figure 2 Sample Location Map Appendix A Analytical Reports

Skipanon Bridge March 2023

1. Introduction The Oregon Department of Transportation (ODOT) Region 2 Hazardous Materials Group (HazMat) has conducted this Hazardous Structural Materials Report (HSMR) for the Skipanon Bridge, located at OR 104 Spur, MP 4.62, Clatsop County, Key # M23004. The purpose of this report is to document the survey(s) of potentially hazardous materials on the structures that will be disturbed by the proposed construction activities. These materials include asbestos, lead-, cadmium- and chromium-containing paint and other hazardous materials.

1.1. Project Description

The project is located on OR 104 Spur from milepost 4.62 Clatsop County as shown on the Project Area Map, Figure 1. The structure being surveyed is the Skipanon Bridge, ODOT Bridge ID #01400 which crosses the Skipanon River. Work will include removing and replacing the 36-foot long, center span.

1.2. Historical Data on Structure

The Structure was constructed during the late 1920s or early 1930s. Asbestos and lead paint were in common usage at the time.

Historical plan sheets available on the ODOT Bridge System database were reviewed for evidence of past hazardous materials use in construction. Evidence of asbestos containing materials (ACM) was not noted in plan sheets 3756 and 3757. The structure’s steel and wood girders are painted.

Suspect ACM may be in the deck expansion joint seal. The bridge center span pavement does not include a membrane.

2. Asbestos Survey If ACM material may be disturbed, an asbestos survey is required pursuant to OAR 340-248-0240.

ODOT requires special provision SP00295 be included in projects where asbestos may be encountered.

On January 25, 2023, Asbestos Hazard Emergency Response Act (AHERA) inspector from ODOT Region 2 HazMat, Joe Fassio, conducted a visual survey of affected locations and collected a total of 2 samples for analysis. Samples were submitted to NVL Lab of Seattle, Washington to visually estimate bulk asbestos content using polarized light microscopy (PLM). The samples were collected from the bridge deck and included expansion joint sealer and asphaltic crack seal. The sample locations are shown on Figure 2.

A utility conduit for a communications line was identified on the bridge structure. It is not known if the utility contains any ACM within the steel conduit. It is not anticipated that the pipe will be removed during construction.

The samples were placed in individual zip-top baggies and labeled with a unique sample identification code number immediately upon collection. The sample locations were noted in the field. Standard chain-of-custody protocols were used to document and ensure a continuous record of sample possession from the time of sample collection until sample receipt by the laboratory.

Field decontamination procedures for non-disposable sampling equipment (e.g., knives, scrapers) consisted of wiping the equipment off using a clean disposable wipe between samples. Multiple layers of materials were not separated, but instead were submitted as a single sample.

Skipanon Bridge March 2023

Asbestos sampling results are summarized in Table 1 and analytical laboratory reports are included in Attachment A. No asbestos was detected in the samples that were collected.

Table 1 – Asbestos Sampling Results

Sample ID ODOT Sample Description

Laboratory Sample Description

Friable? Analytical Result

M23004-03 Black asphaltic crack seal Black asphaltic material No NAD

M23004-04 Black expansion joint sealer Black asphaltic material No NAD

NAD = No Asbestos Detected

3. Paint Survey Historically, lead was commonly added to paint to increase durability and resist moisture that causes corrosion. In addition to lead, cadmium and chromium have also been added to paint and other coatings. Painted members of the structure include green painted bridge steel and wood girders.

If painted material may be disturbed, a survey is required to meet State and Federal requirements for worker safety and waste material handling and disposal. ODOT requires special provision SP00296 be included in projects where lead, cadmium or chromium is encountered, at any concentration.

On January 23, 2023, Joe Fassio, conducted a visual survey of painted materials and collected 2 paint samples for total metals analysis. Paint chips were collected from painted wood and steel, representative of the waste stream from span 2, which will be demolished. Samples were submitted to Laboratory to measure the lead, cadmium and chromium using US Environmental Protection Agency (EPA) Method 6010.

The samples were placed in individual zip-top baggies and labeled with a unique sample identification code number immediately upon collection. The sample locations were noted in the field. Standard COC protocols were used to document and ensure a continuous record of sample possession from the time of sample collection until sample receipt by the laboratory. Field decontamination procedures for non-disposable sampling equipment (e.g., knives, scrapers) consisted of wiping the equipment off using a clean disposable wipe between samples. Multiple layers of paint were not separated, but instead were submitted as a single paint sample. Analytical laboratory reports are included in Attachment B.

Laboratory data for total metals is summarized in Table 2 below.

Skipanon Bridge March 2023

Table 2 – Paint Sampling Results – Total Metals

Sample ID ODOT Sample Description Lead

(mg/kg) Cadmium (mg/kg)

Chromium (mg/kg)

M23004-01 Green wood bridge rail paint 150 <19.0 6,100

M23004-02 Green steel I-beam paint 120 <21 51,000 mg/kg = milligrams per kilogram

According to the Resource Recovery and Conservation Act (RCRA) “Rule of 20”, if a total metals result that is 20 times or more than the EPA Hazardous Waste Action Level (Action Level), the waste may be characteristic of a hazardous waste. The TCLP analytical method is used to determine whether a waste exceeds the Action Level. If a material exceeds the Action Level, the material must be handled, transported and disposed as a hazardous waste. If a material does not exceed the Action Level, it can be handled, transported and disposed as a solid waste.

As shown in Table 2, the reported total lead and cadmium concentrations in the analyzed paint samples are more than 20 times the Action Levels for these metals. Region 2 HazMat requested TCLP lead/chromium/cadmium analyses on M23004-02. Laboratory data for TCLP metals is summarized in Table 3 below. There was not enough paint sample to test M23004-01. Although the paint in this sample contains elevated lead and chromium, the painted wood with a lead or chromium-based paint does not need to be disposed at a hazardous waste landfill (ODOT, 2010).

The wood can be reused whole by ODOT or others or burned at a facility that has a Stationary Source Permit from the DEQ that allows the facility to burn wood for energy recovery. The facility must be permitted to burn treated wood. The wood can also be disposed at a permitted municipal solid waste landfill or a permitted construction and demolition landfill.

Table 3 – Paint Sampling Results – TCLP Metals

Sample ID ODOT Sample Description Lead

(mg/L) Cadmium

(mg/L) Chromium

(mg/L)

M23004-02 Green steel I-beam paint <0.2 NT 690

EPA Hazardous Waste Action Level 5 1 5 mg/L = milligrams per liter NT = not tested Chromium was detected in the paints sample. The reported TCLP chromium concentration is above the applicable Action Levels. Based on these results, the painted steel demolition materials that would be generated by the proposed construction activities are characteristic of a hazardous waste. The painted metal should either be reused by ODOT or recycled. The contractor should provide the recycling facility the lead and chromium testing results. Metal that cannot be reused or recycled as scrap because of severe corrosion or that it is deemed unsuitable for reuse or recycling would need to be disposed as a hazardous waste at a landfill permitted to accept

Skipanon Bridge March 2023 hazardous waste (RCRA Subtitle C). The hazardous waste determination was calculated on a total volume basis of the bulk waste based on the following formula (ODOT, 2010):

TCLP lead/cadmium/chromium result of paint {mg/L} x paint thickness {in meters} or volume {in cubic meters} / metal thickness {in meters} or volume {in cubic meters} = Maximum TCLP Based on estimated minimum paint thickness of 0.04 inches (one mil minimum) and steel thickness of 0.57 inches (for 18” x 49# I-beam shown in Plan #3757 and typical steel I-beam thickness for that size) the maximum TCLP would be 48 mg/L which exceed the 5 mg/L chromium regulatory limit for a hazardous waste as shown below:

690 mg/l X (0.04 inches/0.57 inches) = 48.4 mg/L

Any paint or painted waste materials that are either disturbed or removed for construction must be handled according to Special Provision 00296. Lead/cadmium/chromium concentrations in paint represent a potential hazard for workers. Work safety activities should conform to Occupational Safety and Health Administration (OSHA) regulations for lead, cadmium and chromium. Work should be managed to prevent paint or painted materials from entering the environment.

4. Other Hazardous Materials The Structure was surveyed to determine if other materials may be present which could be hazardous materials or materials requiring special disposal. The bridge railing is made of treated timbers. Upon removal, treated wood must be disposed of as solid waste according to Standard Provision 00290.20(c)(3)(c).

5. Recommendations Based on the data presented herein, ODOT Region 2 HazMat recommends the following:

• No asbestos abatement work is required for the Project. Special Provision 00295 will be needed to document these results.

• Lead and chromium were found in painted elements in span 2. Special Provision 00296 will be required to address OSHA worker safety and DEQ waste management requirements.

• Treated wood is present in the work area. Wood removed for the project will need to be treated as solid waste in accordance with 2021. Oregon Standard Specifications for Construction 00290.20(c)(3)(c)

If the project scope of work should change, if potential hazardous structures/building materials not described in the report are encountered or if site conditions are not as described, then all work should stop and Region 2 HazMat should be contacted so that additional assessment can be conducted.

6. Limitations As required by ODOT Policy ENV 16-02, Region 2 HazMat performed a hazardous structural material survey to identify potential hazardous materials on Structure including asbestos, lead/cadmium/chromium and PCBs. This inspection report is for internal ODOT use only and may

Skipanon Bridge March 2023 not be relied upon by any other entity without the written permission of an authorized ODOT representative. No environmental assessment can wholly eliminate uncertainty regarding the potential for environmental conditions in connection with a site. Performance of a site assessment is intended to reduce but not eliminate uncertainty regarding the existence of environmental conditions in connection with the site. Finally, this report does not warranty against changes in land use or environmental conditions at the site or adjoining properties subsequent to publishing this report.

Due to the nature of any renovation or demolition activity, the potential exists for discovering suspect ACMs, lead, cadmium, chromium or PCBs that were not covered in this report. If additional suspect ACMs, lead, cadmium, chromium or PCBs are discovered during renovation or demolition, work activities must stop and sampling should be completed by qualified personnel.

If you have any questions please contact Joe Fassio at 503-881-1735.

7. Signatures

Joe Fassio, R.G.

ODOT Geologist

Kyle Roslund, R.G.

ODOT Geologist, Hazmat Coordinator

Signature of Corporate Reviewer Alvin Shoblom, P.E.

Skipanon Bridge March 2023

8. References

ODOT 2010, OTIA III Bridge Delivery Program Materials and Contamination Performance

Standards Manual, dated March 4, 2010

01/24/2024

01/24/2023

ONLINE AHERA ASBESTOS INSPECTOR REFRESHER

Course Date:

Expiration Date:Certificate: IRO-23-9014B for

Course Location:

For verification of the authenticity of this certificate contact:

PBS Engineering and Environmental Inc.

Andy Fridley, Instructor

In accordance with TSCA Title II, Part 763, Subpart E, Appendix C of 40 CFR

4-Hour Online AHERA Inspector Refresher

Training; AHERA is the Asbestos Hazard

Emergency Response Act enacting Title II of Toxic Substance Control Act (TSCA)

HAS SUCCESSFULLY COMPLETED THE TRAINING COURSE

JOE FASSIO

THIS IS TO CERTIFY THAT

CCB #SRA0615 4-Hr Training

Online

4412 S Corbett Avenue

Portland, OR 97239

503.248.1939

Skipanon Br

Figure 1 Project Location Map

North hwye23y Oval hwye23y Oval hwye23y Oval hwye23y Text Box M23004-01 hwye23y Text Box M23004-02 hwye23y Text Box M23004-04 hwye23y Text Box M23004-03 hwye23y Text Box M23004-04 hwye23y Oval hwye23y Oval hwye23y Text Box Figure 2 Sample Location Map

Appendix A

Laboratory Analytical Reports

Munaf Khan, Laboratory Director

Client Project: MBM23-026 Location: OR1045 Skipanon Bridge

Dear Mr. Fassio, Enclosed please find test results for the 2 sample(s) submitted to our laboratory for analysis on 1/30/2023.

Examination of these samples was conducted for the presence of identifiable asbestos fibers using polarized light microscopy (PLM) with dispersion staining in accordance with U. S. EPA 40 CFR Appendix E to Subpart E of Part 763, Interim Method for the Determination of Asbestos in Bulk Insulation Samples and EPA 600/R-93/116, Method for the Determination of Asbestos in Bulk Building Materials.

For samples containing more than one separable layer of materials, the report will include findings for each layer (labeled Layer 1 and Layer 2, etc. for each individual layer). The asbestos concentration in the sample is determined by calibrated visual estimation.

For those samples with asbestos concentrations between 1 and 10 percent based on visual estimation, the EPA recommends a procedure known as point counting (NESHAPS, 40 CFR Part 61). Point counting is a statistically more accurate means of quantification for samples with low concentrations of asbestos.

The detection limit for the calibrated visual estimation is <1%, 400 point counts is 0.25% and 1000 point counts is 0.1%

Samples are archived for two weeks following analysis. Samples that are not retrieved by the client are discarded after two weeks.

Thank you for using our laboratory services. Please do not hesitate to call if there is anything further we can assist you with.

Sincerely, Enc.: Sample Results

February 1, 2023

Joe Fassio ODOT Region 2 455 Airport Rd SE Salem, OR 97301

RE: Bulk Asbestos Fiber Analysis; NVL Batch # 2301646.00

< Client:

Address:

Attention: Mr. Joe Fassio OR1045 Skipanon Bridge

Client Project #: MBM23-026

Samples Received: 2

By Polarized Light Microscopy Bulk Asbestos Fibers Analysis

ODOT Region 2 455 Airport Rd SE Salem, OR 97301

Method: EPA/600/R-93/116 Samples Analyzed: 2

Project Location:

Batch #: 2301646.00

Date Received: 1/30/2023

23010633Lab ID: Client Sample #:

Location: OR1045 Skipanon Bridge

M23004-03

Layer 1 of 1 Description: Black asphaltic material Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %

Asphalt/Binder, Asphaltic Particles 2%Cellulose None Detected ND

23010634Lab ID: Client Sample #:

Location: OR1045 Skipanon Bridge

M23004-04

Layer 1 of 1 Description: Black asphaltic material Non-Fibrous Materials: Other Fibrous Materials:% Asbestos Type: %

Asphalt/Binder, Asphaltic Particles <1%Cellulose None Detected ND

Note: If samples are not homogeneous, then subsamples of the components were analyzed separately. All bulk samples are analyzed using both EPA 600/R-93/116 and EPA 40 CFR Appendix E to Subpart E of Part 763 with the following measurement uncertainties for the reported % Asbestos (1%=0-3%, 5%=1-9%, 10%=5-15%, 20%=10-30%, 50%=40-60%). This report relates only to the items tested. If sample was not collected by NVL personnel, then the accuracy of the results is limited by the methodology and acuity of the sample collector. This report shall not be reproduced except in full, without written approval of NVL Laboratories, Inc. It shall not be used to claim product endorsement by NVLAP or any other agency of the US Government

Client Alex SheaAnalyzed by:

Munaf KhanReviewed by:

01/31/2023 Date:

02/01/2023Date:

Sampled by:

Munaf Khan, Laboratory Director

ASB-02

ODOT Region 2 2301646.00

Company NVL Batch Number

Total Number of Samples

OR1045 Skipanon Bridge

5 DaysTAT

2/6/2023Due Date 9:30 AMTime

() -Fax joe.fassio@odot.oregon.govEmail

Project Manager Mr. Joe Fassio

(503) 758-6433Cell

Phone

Rush Samples

Rush TAT NoAH

MBM23-026Project Name/Number: Project Location:

Sample ID Description A/RLab ID

ASBESTOS LABORATORY SERVICES

Subcategory Item Code

PLM Bulk

Metals ASB-02 EPA 600/R-93-116 Asbestos by PLM <bulk>

455 Airport Rd SE Salem, OR 97301

Address

M23004-031 A23010633 M23004-042 A23010634

Office Use Only Print Name Company Date TimeSignature

Faxed Emailed

Company Date TimeSignature ClientSampled by

Kelly AuVuReceived by

Federal ExpressRelinquished by

Alex SheaAnalyzed by Results Called by

NVL

NVL

1/30/23 1/31/23

Print Name

Entered By: Kelly AuVu

Date: 1/30/2023 Time: 10:08 AM

Special Instructions:

Sincerely, Nick Ly, Technical Director

RE: Total Metal Analysis Method: EPA 6010 (price per analyte) <paint> Item Code: ICP-M2

January 31, 2023

ODOT Region 2 Joe Fassio

455 Airport Rd SE Salem, OR 97301

Enc.: Sample results

NVL Batch # 2301645.00

Client Project: MBM23-026 Location: OR1045 Skipanon Bridge

Dear Mr. Fassio, NVL Labs received 2 sample(s) for the said project on 1/30/2023. Preparation of these samples was conducted following protocol outlined in EPA 3051/6010D, unless stated otherwise.

Analysis of these samples was performed using analytical instruments in accordance with EPA 6010 (price per analyte) <paint> . The results are usually expressed in mg/kg and ppm. Test results are not blank corrected.

For recent regulation updates pertaining to current regulatory levels or permissible exposure levels, please call your local regulatory agencies for more detail.

At NVL Labs all analyses are performed under strict guidelines of the Quality Assurance Program. This report is considered highly confidential and will not be released without your approval. Samples are archived after two weeks from the analysis date. Please feel free to contact us at 206-547-0100, in case you have any questions or concerns.

Total Metals

Lab ID Client Sample # Sample wt (g)

Results in mg / kg

RL

mg / kg

Results in ppmElements

Analysis Report

OR1045 Skipanon Bridge

ODOT Region 2Client:

455 Airport Rd SE Salem, OR 97301

Mr. Joe FassioAttention:

Address:

Project Location: Samples Received: 2 Samples Analyzed: 2

Batch #: 2301645.00

Date Received: 1/30/2023

Matrix: Paint Method: EPA 3051/6010D

Client Project #: MBM23-026

19.019.0Cadmium (Cd) < < 19.00.2122 .. 6100.019.0Chromium (Cr) 6100.00.2122 .. 150.019.0Lead (Pb) 150.00.2122

23010631 M23004-01

21.021.0Cadmium (Cd) < < 21.00.1938 .. 51000.021.0Chromium (Cr) 51000.00.1938 .. 120.021.0Lead (Pb) 120.00.1938

23010632 M23004-02

ICP-M2

ClientSampled by:

Shalini PatelAnalyzed by:

Nick LyReviewed by:

Note : Method QC results are acceptable unless stated otherwise.

Bench Run No: 2023-0130-05 mg/ kg = Milligrams per kilogram RL = Reporting Limit ppm = Parts per million '<' = Below the reporting Limit

01/30/2023Date Analyzed:

01/31/2023Date Issued:

Unless otherwise indicated, the condition of all samples was acceptable at time of receipt.

ODOT Region 2 2301645.00

Company NVL Batch Number

Total Number of Samples

OR1045 Skipanon Bridge

10 DaysTAT

2/13/2023Due Date 9:30 AMTime

() -Fax joe.fassio@odot.oregon.govEmail

Project Manager Mr. Joe Fassio

(503) 758-6433Cell

Phone

Rush Samples

Rush TAT NoAH

MBM23-026Project Name/Number: Project Location:

Sample ID Description A/RLab ID

METALS LABORATORY SERVICES - PER

ANALYTE TEST

Subcategory Item Code

Inductively Coupled Plasma (ICP) - Group Tests

Cadmium (Cd), Chromium (Cr), Lead (Pb)Metals ICP-M2 EPA 6010 (price per analyte) <paint>

455 Airport Rd SE Salem, OR 97301

Address

M23004-011 A23010631 M23004-022 A23010632

Office Use Only Print Name Company Date TimeSignature

Faxed Emailed

Company Date TimeSignature ClientSampled by

Kelly AuVuReceived by

Federal ExpressRelinquished by

Shalini PatelAnalyzed by Results Called by

NVL

NVL

1/30/23 1/30/23

Print Name

Entered By: Kelly AuVu

Date: 1/30/2023 Time: 10:04 AM

Special

Sincerely, RE: Total Metal Analysis Method: EPA 1311/6010 <Bulk> (Price per analyte) Item Code: TCLP-M2

March 1, 2023

ODOT Region 2 Joe Fassio

455 Airport Rd SE Salem, OR 97301

Enc.: Sample results

NVL Batch # 2302930.00

Client Project: MBM23-026 Location: OR1045 Skipanon Bridge

Dear Mr. Fassio, NVL Labs received 1 sample(s) for the said project on 2/22/2023. Preparation of these samples was conducted following protocol outlined in EPA 1311/6010D, unless stated otherwise.

Analysis of these samples was performed using analytical instruments in accordance with EPA 1311/6010 <Bulk> (Price per analyte). The results are usually expressed in mg/L and ppm. Test results are not blank corrected.

For recent regulation updates pertaining to current regulatory levels or permissible exposure levels, please call your local regulatory agencies for more detail.

At NVL Labs all analyses are performed under strict guidelines of the Quality Assurance Program. This report is considered highly confidential and will not be released without your approval. Samples are archived after two weeks from the analysis date. Please feel free to contact us at 206-547-0100, in case you have any questions or concerns.

Analysis Report

Lab ID Client Sample # Results in mg / L RL in mg / L

Results in ppmElements

OR1045 Skipanon Bridge

ODOT Region 2Client:

455 Airport Rd SE Salem, OR 97301

Mr. Joe FassioAttention:

Address:

Project Location: Samples Received: 1 Samples Analyzed: 1

Client Project #: MBM23-026

Batch #: 2302930.00

Date Received: 2/22/2023

Matrix: Bulk Method: EPA 1311/6010D

Toxicity Characteristic Leaching Procedure (TCLP)

6900.20 0.200.20

23017985 M23004-02 Chromium (Cr) Lead (Pb) <

0.20

TCLP-M2

ClientSampled by:

Shalini PatelAnalyzed by:

Nick LyReviewed by:

Note : Method QC results are acceptable unless stated otherwise.

Bench Run No: 2023-0227-06 mg/ L = Milligrams per liter RL = Reporting Limit N/A = Not Applicable '<' = Below the reporting Limit

02/28/2023Date Analyzed:

03/01/2023Date Issued:

Unless otherwise indicated, the condition of all samples was acceptable at time of receipt.

ODOT Region 2 2302930.00

Company NVL Batch Number

Total Number of Samples

OR1045 Skipanon Bridge

5 DaysTAT

3/1/2023Due Date 8:35 AMTime

() -Fax joe.fassio@odot.oregon.govEmail

Project Manager Mr. Joe Fassio

(503) 758-6433Cell

Phone

Rush Samples

Rush TAT NoAH

MBM23-026Project Name/Number: Project Location:

Sample ID Description A/RLab ID

METALS LABORATORY SERVICES - PER

ANALYTE TEST

Subcategory Item Code

Inductively Coupled Plasma (ICP) - Group Tests

Chromium (Cr), Lead (Pb)Metals TCLP-M2 EPA 1311/6010 <Bulk> (Price per analyte)

455 Airport Rd SE Salem, OR 97301

Address

M23004-021 A23017985

Office Use Only Print Name Company Date TimeSignature

Faxed Emailed

Company Date TimeSignature ClientSampled by

Kelly AuVuReceived by

ClientRelinquished by

Shalini PatelAnalyzed by Results Called by

NVL

NVL

2/22/23 2/28/23

Print Name

Entered By: Kelly AuVu

Date: 2/22/2023 Time: 8:50 AM

Special