Sample_ACM_Compliance.docx
DOCX document 250 KB Posted
- Attached to
- Annex EV Chargers
- Solicitation number
- 2026-MPW-162
- Issued by
- Pierce County, Washington
About this file
This is a Statement of Compliance form issued by Pierce County, Washington, requiring contractor attestation regarding asbestos-containing materials (ACM) awareness for construction projects. The form mandates that contractors acknowledge receipt and understanding of the asbestos inspection report included in bidding documents, confirm awareness of all known ACM locations within the project area, and ensure all employees and subcontractors are informed of potential hazardous materials. The contractor must attest that they have read and understand the limitations and findings of the asbestos survey, and that subcontractors have been notified of all identified ACM locations. The form requires the authorized company representative to sign, print their name, provide their title, and date the document prior to project commencement.
The compliance statement references W.A.C. 296-62-07721 and PSCAA Regulation III, Article 4 as the governing regulatory standards. The form outlines specific responsibilities for employees and contract personnel who encounter suspect ACM, including contacting the facility owner, consulting the inspection report, and treating any unsampled suspect materials as presumed asbestos-containing until proven otherwise through sampling and Polarized Light Microscopy (PLM) analysis. This document serves as a binding attestation that protects both the county and contractors by establishing documented awareness of asbestos hazards and establishing clear protocols for material identification and worker safety.
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Text version
(SAMPLE FORM)
Statement of Compliance Project:
Project No.:
Contract No. SC-
In accordance with W.A.C. 296-62-07721 and PSCAA Regulation III, Article 4, (insert name of firm preforming survey) has performed an asbestos survey of the subject structure located at (insert name and address location of facility(s)), documented in report titled: (insert title of report). Should employees or contract personnel encounter any suspect asbestos-containing materials (ACM) it is their responsibility to:
1. Contact a representative of the Owner.
2. Consult the referenced inspection report whether the suspect material contains asbestos.
3. If identified suspect material is not included in referenced inspection report, the suspect material is not sampled and presumed containing asbestos until otherwise proven by sampling and PLM analysis.
4. Ensure all employees and contractors, who may disturb suspect materials, are informed, and advised of the location and type of suspected ACM.
I Hereby Attest:
The inspection report included in the bidding documents is read and understood by the contractor and all the subcontractors the limitations and the findings of the survey. In addition, the contractor assures the subcontractors are informed of all known locations with ACM.
I am authorized to sign on behalf of my company.
Contractor: _____________________________ Signature: _____________________________ Print Name: _____________________________ Title: _____________________________ Date: _____________________________
Pierce County ACM Compliance Form 3/31/2021 image1.tif
File details come from the government source that posted it. Updated .