J-0200000-05 2080 Asbestos Abatement Forms.pdf

FORM 02080A

CERTIFICATE OF WORKER’S ACKNOWLEDGMENT

I , HEREBY ACKNOWLEDGE that I have voluntarily chosen to participate in work that involves the removal and/or transportation of asbestos-containing materials from the property at 3013 West Huron River Drive, Scio Township, Michigan.

I am aware that this asbestos work is a hazardous activity that will involve exposure to asbestos, and that exposure to asbestos can cause cancer, lung disease and other illness. I am aware that my employer, ______________________________, has taken full responsibility to supply me with proper respiratory protection equipment and other personal protective equipment, training in proper asbestos abatement procedures, and annual medical examinations at no cost to myself. I am also aware that proper safety equipment and training may not prevent me from being harmed by exposure to asbestos.

Date:

Signature

Witness' name

Witness' signature Date:

TRANSLATOR'S ACKNOWLEDGMENT: I certify that I translated this document to the signing employee accurately.

Translator's name:

Translator's signature: Date:

FORM 02080B

CERTIFICATE OF VISUAL INSPECTION

Project Name: ___________________________________________________

Building Name/Number: ___________________________________________________

Work Area Description: ___________________________________________________

In accordance with Section 02080, Removal of Asbestos Containing Materials, the CONTRACTOR hereby certifies that he has visually inspected the work area (all surfaces, including pipes, beams, ledges, walls, ceiling and floor, decontamination unit, sheet plastic, etc.)

and has found no dust, debris or residue.

By: ____________________________________________ Date:_________________ (Signature)

(Print Name) (Print Title)

(Print Company Name)

OWNER’S REPRESENTATIVE CERTIFICATION

The OWNER’S REPRESENTATIVE hereby certifies that he/she has accompanied the CONTRACTOR on CONTRACTOR’s visual inspection and verifies that this inspection has been thorough, and to the best of OWNER’S REPRESENTATIVE’s knowledge and belief, the CONTRACTOR’s Certification above is a true and honest one.

FORM 02080C

POST-ABATEMENT FINAL INSPECTION/AIR SAMPLING FORM

CLIENT:

PROJECT:

LOCATION:

TYPES OF ACM:

INSPECTION CHECKLIST

Yes / No The asbestos abatement Contractor was present during the visual inspection.

Yes / No A written detailed scope of work or written specification was provided prior to the inspection to verify all required asbestos-containing materials were removed.

Yes / No All materials and equipment were properly removed from the work area according to the scope of work or written specification.

Yes / No Plastic sheeting present in the work area was wet wiped to remove visible debris.

Yes / No All surfaces, materials, and equipment not covered with plastic sheeting in the work area were wet wiped to remove visible debris.

Yes / No Decontamination units were wet wiped to remove visible debris and waste was properly filtered or bagged.

Signature of Inspector: _______________________________ Date: ________________ Printed Name: ________________________________ Time: ________________ Certification State and No: _____________________________

ENCAPSULATION AND CLEARANCE AIR MONITORING CHECKLIST

Yes / No Lock down encapsulant was applied to all specified surfaces.

Yes / No Clearance air sampling was specified or required for this work.

PCM / TEM Type of clearance air samples collected.

• If PCM, minimum of 3 samples required per work area; area clear if all samples results less than or equal to 0.01 fibers per cubic centimeter (f/cc).

• If TEM, 5 inside work area samples required; area clear if average is less than or equal to 70 structures per square millimeter (s/mm2).

Other criteria? Explain ________________________________________________

Sample No.:

PCM

Result:

1)________ 2)_______ 3)_______ 4)_______ 5)_______ 6)________

TEM

Result:

1)________ 2)_______ 3)_______ 4)_______ 5)_______ 6)________

Comments: ______________________________________________________________________

Signature of Inspector: _______________________________ Date: ________________ Printed Name: ________________________________ Time: ________________ Certification State and No: _____________________________

FORM 02080

CERTIFICATE OF COMPLETION

Project Name: ___________________________________

Building Name/Number: ___________________________________

I, the undersigned, certify that the asbestos removal portion of the work which occurred on _____________________________ (Date(s)) has been performed according to Federal, state and local regulations, “state-of-the-art” technologies, and in accordance with specifications and drawings for this project.

OWNER’S REPRESENTATIVE CERTIFICATION

The OWNER’S REPRESENTATIVE hereby certifies that he/she has inspected the CONTRACTOR’s work and verifies that the work has been performed in accordance with the above-referenced documents, and to the best of OWNER’S REPRESENTATIVE’s knowledge and belief, the CONTRACTOR’s Certification above is a true and honest one.