Ref_Doc_-_Sample_ACM_Compliance.docx

This is a Statement of Compliance form issued by Pierce County, Washington, requiring asbestos-containing materials (ACM) identification and management procedures for contractors performing work on county facilities. The document mandates that contractors and subcontractors acknowledge receipt and understanding of the asbestos inspection report included in bidding documents for the M&O Facility LED Lighting Replacement Project at the Central Maintenance Facility. The form requires designated company representatives to attest that they have read and understood the limitations and findings of the asbestos survey, that all subcontractors have been informed of known ACM locations, and that employees and contract personnel are prepared to follow established protocols if suspect materials are encountered during project execution.

The compliance form establishes four key responsibilities for personnel who may encounter suspect ACM: contacting the facility owner's representative, consulting the inspection report to determine if materials are documented, presuming undocumented suspect materials contain asbestos until proven otherwise through sampling and polarized light microscopy analysis, and ensuring all affected employees and contractors are informed of ACM locations and types. The contractor must complete the form by providing company name, authorized signatory signature, printed name, title, and date. This document serves as a binding acknowledgment that the contractor understands asbestos-related hazards and compliance requirements under Washington Administrative Code 296-62-07721 and PSCAA Regulation III, Article 4, ensuring worker safety and regulatory adherence throughout the project duration.