Sample_ACM_Statement_of_Compliance_Form.pdf

This is a Pierce County Statement of Compliance form related to asbestos-containing materials (ACM) survey documentation for facilities management general contractor services in Washington. The form requires contractors and subcontractors performing work on Pierce County facilities to acknowledge receipt and understanding of an asbestos inspection report for the subject structure. The form mandates that all personnel who may encounter or disturb suspect ACM materials must be informed of their locations and types, must contact the property owner if suspect materials are discovered, and must reference the inspection report to determine whether materials contain asbestos. Any suspect materials not documented in the inspection report are presumed to contain asbestos until proven otherwise through sampling and polarized light microscopy (PLM) analysis. The form requires authorized company representatives to certify their understanding of the inspection report's limitations and findings and to confirm that all subcontractors have been informed of known ACM locations.

The compliance requirements are established under W.A.C. 296-62-07721 and PSCAA Regulation III, Article 4. This form serves as a safeguard for workers in Pierce County court facilities, general office buildings, and correctional facilities, including jail facilities, where construction and facility modification projects occur. Contractors must complete and sign the form prior to commencing work, providing their company name, signature, printed name, title, and date of attestation.