HomeMy WebLinkAbout202 Stoney Brook St - Special Inspections/Field Verification - 01/22/2019Planning, Development & Transportation Ser-trices
C . ®f Community Development & Neighborhood Services
6 ■ 281 North College Avenue
® �o 'ns P.O.liox580
�wti� Fort Collins, CO 80522.0580
�,_ 970A16.2740
970.224.6134- fax
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Asbestos Statement Disclosure1 00490
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Address Permit #
In accordance with the State of Colorado Senate Bill 13452, property owners, applying for a
remodel permit, shall indicate their awareness about their property having been inspected for
Asbestos Containing Materials (ACMs).
Property owner, please check the appropriate box below and sign:
❑ I do not know if an asbestos inspection has been conducted on this property.
E(�n asbestos inspection has been conducted on this property on or about
9 /!S
❑ An asbestos inspection has not been conducted on this property.
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Signature QQ Date
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Your remodel project may be subject to State and Federal Regulations requiring an inspection
for ACMs. Asbestos can be found in these and many other building materials: ceiling tiles and
textures, vinyl floor coverings and mastic, boiler and pipe insulation, heating and cooling duct
insulation, roofing products and clapboard shingles, etc.
For more information aboutAsbestos or forms, please contact:
Asbestos Compliance Assistance Group
Toll Free: 1-800-886-7689
Phone: (303) 692-3100
https:/lwww.colorado.gov/pacific/sites/default/files/AP ASB RenovationDemolition.pdj
https: //www. codorado. gov/cdphelasbestos
Email address: cdphe.asbestos6E�state.co.us
Page 1 of 1
ASBESTOS ABATEMENT FINAL VISUAL INSPECTION F �i1 0 4 4
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Facility
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Inspected By
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Phase / Containment
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Final Visual Beg/Pass Dates
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Contractor/Supervisor
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Final Clearance Bcg/Pass Dates
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Containment Type ❑FFull ❑Secondary r1 QOther
Descri Han of Area: O¢ f i a-r W XA d oj jr
Co--.a.A.est VqA
Abatement Methods ❑ Gross removal ❑ Non -friable CaCoTponent
Scope of Work/Materials Removed: b uwOt
❑ Glove -bag ❑ Other
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FINAL VISUAL INSPECTION SUMMARY
FINAL VISUALINSPECTION (PRE, LOCIO30WN)
Description
All asbestos within the scope ofavork is removed.
No residual debris, dust or streaking an floors
No residual debris, dust or streaking on walls
No residual debris, dust orstreaking on ceilings
No residual debris, dust or streaking on on teal barriers or other surface covered by poly
No residual debris, dust or streaking on piping, nip ofducts, or other mechanical equipment
No residual debris, dust or streaking between decks and beams, behind eolumas
All protective Primary and Secondary barriers removed with only critical barriers in place
No residual dust, debris or streaking on hangers, light furlures, or other fixed objects / surfaces
within containment.
Negative pressure containment continually operating. New prefilters and secondary filters
installed in negative air machines
All waste containers removed front area, labeled and stored. All equipment dean
Attached decontamination unit and waste load out units cleaned, with no residual debris, dust or
streaking.
Number of Inspections Required to Pass ( )2 ( )3 ( )4 ()5
t,ommerraal receinal Fan =-6= UFM (hlghl -EO' of air travel
Descri Ilon
Commenls
High Volume Pumps
>3205011` ndnimumof5 plus 1,_a205011`2 minimum,
<3s031f I minimum
-.Cassettes
0.80pm 25mm MCE cassettes, I lab and l field blank for each set
Extension Cords/GFCI
GFCI Protected Surge Prefemore/Outlets
.11ap Leafblower
Leafblow, each 1.000 sq a within the work ores for a duration of5
minutes
flttach sketch or dralving ofcontainment coqfigurarron
LEGEND
✓=OK Y=Defciency/Correction Required —=N/A
Irerracan
CONSULTING ENGINEERS AND SCIENTISTS
AREAS REQUIRING FURTHER CLEANING:
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PLO,�Ss Q11 c6.:�cQ` w
Date Aonlyaed: Laboratory: AIHA/NVLAP o:
,PASSED ( ) FAILED C RANCE STANDARDS
Comments: '
Inspector's Signature Date / Time
®=Deficiency Corrected
Final Visual Inspection Form (Rev 07114