Post on 11-Mar-2018
ASBESTOS AND REGULATED WASTEINSPECTION REPORT
Parce1302E16610 53rd Street NortheastRogers, Minnesota 55374
Prepared For:District 3, MN/DOT
Prepared By:Industrial Hygiene Services Corporation
IHSC Project Number: M05-205
June 2006
1
CONTENTS:
Section 1 - Site Specifics and Certification
Section 2 - Summary of Actions Required For This MovelDemolition
Section 3 - Summary of all Asbestos and Regulated Wastes
Appendix I - Chain of Custody Forms and Analytical Results
Appendix II - Structure Location & Floor Plans
Appendix III - Licenses
2
SECTION 1Site Specifics and Certification
16610 53rd Street Northeast
SP: 8608-21TH: 101Parcel: 302ELocation: 16610 53rd Street Northeast, Rogers, Minnesota (see copies of site mapAppendix II)Number and type of Structure/s: One Residential with Attached GarageCurrent Owner: Mn/DOTExpected Disposition of the Structure: Demolition
Licensure: MDH certified asbestos inspectors (John Hastings, Eric Hjort, and TomSogard) conducted the inspection (Appendix III)
Certification: The undersigned certifies that this asbestos inspection was performed incompliance with MN Rules 4620.3460.
';)Signature: --=-=-~[t..!'..L~!t:"-4-~"'-'d.~'1LI-----;:---,--::-:-::-:c-c:--Amy J. Buckley, Ce
Date: ~(<t>f-"-F-Oh-
Certification: The undersigned certifies that this asbestos and regulated waste inspectionand report was performed under my direct supervision and I have reviewed its contentsand find it to meet or exceed Mn/DOT's contract requirements.
Signature: 4 A.~ ,Stephen A. dross: ertifiid Hazardous Materials Manager License # 1776
Date: b!B (tJ6
3
SECTION 216610 53'd Street Northeast
Summary of Actions Required For This Demolition
Asbestos Summary: The structure contained the following category I or II asbestoscontaining materials:
}> I each black sink undercoating located in kitchen 1 in good condition
The structure contained the following friable asbestos containing materials:}> 1 each light fixture heat shield located in hallway 1 in good condition}> 2 square feet gray linoleum located in hallway 2 in good condition
These materials are required to be removed for a demolition (See documents inSection 3 for the detailed sample locations, amounts, conditions and summary inventoryof all suspect materials).
Regulated Waste Summary:The following regulated waste found in the kitchen, living room, dining room, watercloset 1, bedroom 2, water closet 2, hallwayl, hallway 2, basement, pole barn and theslab.
Mercury:2 ft Fluorescent Bulb: I each4 ft Fluorescent Bulb: 5 eachThermostat: 1 eachSilent Switches: 27 each
PCBs:Ballasts: 9 each
CFC's:Refrigerator: 4 eachAir Conditioner (Window): 1 eachAir Conditioner (Central): 1 each
Treated Wood:CCA (green treat): 400 linear feet - Tongue & Groove Green Treat
20 linear feet - 6 x 6 Green Treated Posts100 linear feet - Landscape 6 x 6 Green Treated Posts16 square feet - Green Treated Pad
4
Regulated Waste:Lead Acid Battery: 4 eachTires: 112 eachPropane Tanks: 2 eachSmoke Alarm: 1 eachQuarts of oil: 3 eachGas Tanks: 2 eachGas Cans: 1 eachExhaust Fans: 2 eachClorox Bleach: 1 gallonGarage Door Opener: 1 each
White Goods:Stoves: 3 eachRange Hood: 2 eachDishwasher: 1 eachCeiling Fan: 1 eachDryer: 3 eachWasher: 1 eachWater Heater: 4 eachWater Pressure Tank: 2 eachWater Softener: 2 eachFurnace: 3 eachGrill: 1 each
Solid Waste:Trash: 12 1/4 YardsFurniture: 2 each
This waste is required to be removed before the demolition (See attached documentsin Section 3 for the detailed inventory of all regulated wastes)
Lead Based Paint:None
This waste is required to be stabilized before the demolition (See attached documentsin Section 3 for the detailed inventory of all regulated wastes)
5
SECTION 3Summary of all Asbestos and Regulated Wastes at
16610 53rd Street Northeast
MNffiOT Building Asbestos Inspection Form
One Form Per Structure
Company Perfonning the InspectionCompany's State Work Order NumberCompany's AddressCompany TelephoneInspector(s) Names
MNIDOT DistrictState Project NumberParcel NumberBuilding TypeAddress of StructureInspection Date
Industrial Hygiene Services CorporationMnIDOT Contract Number 885533585 Lexington Ave N, Suite 150, St. Paul, MN, 55126(651) 766-9811John Hastings, Eric Hjort, Tom Sogard
District 38608-21302EOne Residential with Attached Garage1661053'· Street Northeast, Rogers, MN 553744-19-06
Kitchen 1
Total I each
Friable
Black Sink
Undercoating
2%Chrysotile
1 each Good 8A Yes
Hallway 1Light Fixture 85%
1 each Good 9A YesHeat Shield Chrysotile
Hallway 2 Grey Linoleum21% 2 ft2
ChrysotileGood 21A Yes
Total Square Feet 2 sq ft, 1 each
6
DefinitionsSample Description
Condition
Quantity
Type of Homogeneous material i.e. sheetrock, siding,
ExcellentGood
Pooronly if contains> I% asbestos otherwise NA
• Standard Locations: Brl = Bedroom 1Br2~ Bedroom 2 (Etc)
.Kit = Kitchen
DR ~ Dining Room
WCI ~ Bathroom IWC2 = Bathroom 2
CI = Closet 1C2 = Closet 2 (Etc)
UR = Utility RoomFR ~ Family Room
0= Other (Name)
7
HI = Hall I
H2 = Hall 2 (Etc)SI ~Shed 1
S2 = Shed 2 (Etc)
D=DeckY=YardG = Garage
B = BasementEI = Entry 1E2 = Entry 2 (Etc)SW ~ Stairwell
MnlDOT Building Regulated Waste Inspection Form(One Form per Building)
Company Performing the InspectionCompany's State Work Order NmnberCompany's AddressCompany TelephoneInspector(s) Names
MnlDOT DistrictState Project NmnberParcel NumberBuilding TypeAddress of StructureInspection Date
Industrial Hygiene Services CorporationMnlDOT Contract Number 885533585 Lexington Ave N, Suite 150, St. Paul, MN, 55126(651) 766-9811Jolm Hastings, Eric Hjort, Tom Sogard
District 38608-21302EOne Residential with Attached Garage16610 53'd Street Northeast, Rogers, MN 553744-19-06
REGULATED WASTEIMATERIALS
Items Total Quantitv Locations;'siC, •••••••••••••••
•••••••• ·.. iii,i'·' , i< ................. , , ........" .. ,Heat Pumps None ---Air Conditioners 2 Kitchenl, ExteriorFire Extinguishers None ---Refrigerators 4 Exterior, Kitchenl, Kitchen2Freezers None ---Other None ---
in iiioii i· ......•. ,i.....·.. <;i .. ·.;<. .ii'··.·.·.··········...·. ..... ··············.<··i ····ii< .. <'Ballasts 9 Garage, Kitchen 2Transformers None ---Other None ---
.i'i«.<·.·.···· .i .. ·.··,.·,·« ·...·...···.···'<i...P«·ii .·.·.·.i···..·.·.·«< "·.iii·······<4 ft Fluorescent Bulbs 5 Garage, Kitchen 28 ft Fluorescent Bulbs None ---
HID Lamps None ---Thermostats I Hallway ISilent Switches 27 Kitchenl, Kitchen 2, Living
Room I, Living Room 2, FamilyRoom, West Entry, North Entry,
Hallway I, Hallway 2, WCI,WC2, BRI, BR2, BR3, BR4
Other (2 ft Fluorescent Bulbs) I .' Kitchen 21·;'..<1ii.·· , i .<i • .. c·,<··········· <.<
.' .......•......... • i.'· i ........
Lead Plwnbing None ---
Lead Paint . None ---Lead Paint Peeling (Sq Ft) None ---Other (Name) None ---
8
Items Total Quantity LocationsTreatedWolld .... ...
••••••••••...... i···· >
Creosote None ---
CCA (green treat) 400 linear feet-Tongue & Groove Exterior20 linear feet-6x6 Exterior
CCA (green treat) 100 linear feet-landscape 6x6 Exterior16 square feet - pad Exterior
Other (Name if Possible) None ---
l'Ia¢arlllluslReguillte\J ..... ••, .... ...
. ....Paint None ---Oil 3 quarts ExteriorGrease None ---Antifreeze None ---Fuels (Name if Possible) None ---
Lead Acid Batteries 4 GaragePesticideslHerbicides None ---Fertilizers None ---UnknownlUnlabeled Wastes None ---
Televisions None ---Radios None ---
Smoke Alarms I Hallway)Computers/Electronics None ---Refractory BrickIMold None ---Other (Tires) 112 ExteriorOther (Propane Tanks) 2 ExteriorOther (Gas Tanks) 2 ExteriorOther (Gas Can) ) ExteriorOther (Exhaust Fans) 2 WC), AtticlRoofOther (Clorox Bleach) ) gallon Kitchen2Other (Garage Door Opener) I Garage
'ii" ••••••••....... .·.'.i.'···.•>, ../. .. . ..... ,i
Furniture 2 WCI, ExteriorTrash (Estimate Yards) 12 Yo Yards Exterior, Living Room I, Garage,
WC2Stoves 3 Kitchen I, Kitchen 2, ExteriorDishwashers, etc. ) Kitchen IWater Heater 4 Utility Room, Exterior
Furnace 3 North Entry, Garage, UtilityRoom
Other (Water Pressure Tank) 2 Utility RoomOther (Water Softener) 2 ExteriorOther (Grill) I ExteriorOther (Range Hood) 2 Kitchen ), Kitchen 2Other (Ceiling Fan) ) Family RoomOther (Dryer) 3 Hallway 2, ExteriorOther (Washer) ) Exterior
••••••, >< •..•..
•••••••••, . • .> ,..
Septic System None ---
Flammable Waste Trap None ---Sediment Trap None ---Other (Name) None ---
9
Individual LocationsLocation Item Quantitv
Kitchen I Air Conditioner (window) IRefri!!erator I
Silent Switches 2Stoves I
Dishwasher IRange Hood I
Family Room I Silent Switches 2rp;l;no Fan I I
,
Living Room I I Silent Switch I 2I Trash I Y. vard
West Entry I Silent Switches I 2, ,
Hallway I Silent Switches 2Thermostat I
Smoke Alarm I,
Bedroom I ffiRll I Silent Switches I I,
Water Closetl (WCI) Silent Switches 3Furniture I
Exhaust Fan I, ' , , ,
~
,
Bedroom 2 ffiR21 I Silent Switches I 2, ,," , '
Attic/Roof I Exhaust Fan I I, , '
Garage Ballasts 64 ft Fluorescent Bulbs I
Lead Acid Battery 4Garage Door Opener I
Trash I vardFurnace I
, ' ',
" , ,
North Entry I Silent Switch 2Furnace I I
, , "
Kitchen 2 Refri!!erator IBallasts 3
4 ft Fluorescent Bulbs 4Silent Switches 3
2 ft Fluorescent Bulbs IClorox Bleach I !!allon
Stoves IRange Hood I
, ,
Living Room 2 I Silent Switches I I, ,
,', '
10
Individual Locations...... I •• .•.. ····.···.·Itelll< QllantitvWater Closet 2 (WC2) Silent Switches 2
Trash Y, yard..•...
•••••• . ••••••••••••••.
Bedroom 3 (BR3) I Silent Switches I• •
... ..Bedroom 4 (BR4) Silent Switches 1< ••••••• ... . .,
•••• . . > ••••••••••••
Utility Room Water Heater IFumace I
Water Pressure Tank 2
•••• •••••• •••••••••••••• ....... . ...•• > •.... ··.····0 ". ••
. ....
Hallway 2 Silent Switch ITrash Y, yardDryer I
" ..........••••••
..•• • . '" • .......... •
Exterior Tires 112Grill I
Furniture IPropane Tanks 2
Washer IWater Softener 2
Refrigerator 2Quarts or Oil 3
Gas Can IGas Tanks 2
Dryer 2Stove 1
Water Heater 3Air Conditioner (Central) I
Trash 10 yardsCCA (green treat) 400 linear reet - Tongue &
Groove20 linear reet - 6 x 6
100 linear reet - landscape 6 x 616 square reet - pad
, ....... '. .........> . ......... ............ ....• ,······0>.· ...... "> ........... . ..
11
Appendix I16610 53rd Street Northeast
Chain of Custody Forms aud Analytical Results
Building Name: PARCEL 302E, 16610 53RD STREET NORTHEAST, ROGERS, MINNESOTAMnJDOT PROJECT 8608-21, TH 101
IHSC Project No.: M05-205.1
Date: April 19, 2006mINDUSTRIAL
HYGIENESERVICESCORPORATION
Location I Material Identification PhysicaTiD I Quantity I Units T -Sample II I Results
Kitchen 1 Black Sink Undercoating Black 1 Each 8A 2% ChrysotileBlue Linoleum wi Yellow Adhesive 250 Square Feet 5BC None DetectedYellow Adhesive on Blue Linoleum 250 Square Feet 6BC None DetectedSheetrock Walls and Ceiling 550 Square Feet 3' None DetectedStove Pipe Liner Wall 1 Each 11A None DetectedPopcorn Textured Ceiling Material Ceiling 250 Square Feet 1A None Detected
Living Room 1 SheetrockPopcorn Textured Ceilina Material
Wall and CeilingCeiling
650250
Square FeetSquare Feet
3A1B
None DetectedNone Detected
IFamily Room 1 IBlown In Insulation Ceiling I 175 I Square Feet I 10A I None Detected IWest Entry Blue Linoleum wi Yellow Adhesive 75 Square Feet SA None Detected
Yellow Adhesive on Blue Linoleum 75 Square Feet 6A None DetectedPopcorn Textured Ceiling Material Ceiling 50 Square Feet l' None DetectedSheetrock Wall and Ceiling 400 Square Feet 3' None Detected
Hallway 1 Light Fixture Heat Shield 1 Each 9A 85% ChrysotilePopcorn Textured Ceiling Material Ceiling 100 Square Feet 1C None DetectedSheetrock Wall and Ceiling 400 Square Feet 3' None Detected
Water Closet 1 (WC1) Sheetrock Wall and Ceiling 200 Square Feet 3' None DetectedGreen Sheetrock Wall and Ceiling 200 Square Feet 4ABC None DetectedYellow Wallboard Adhesive Wall 40 Square Feet 7A None Detected
Bedroom 1 (BR1)
Bedroom 2 (BR2)
Gliller Textured Ceiling MaterialSheetrock
Gliller Textured Ceiling MaterialSheetrock - 2 lavers
CeilingWall and Ceiling
CeilingWall and Ceilin'
150550
200650
Square FeetSquare Feet
Square FeetSquare Feet
2AB3B
2C3C
None DetectedNone Detected
None DetectedNone Detected
!AlIic IBlown In Insulation Ceiling I 1000 I Square Feet I 10' I None Detected I
* = This result is inferred as consistent with an analyzed sample of the same material from another area.Page 1 of 2
MnlDOT TH 101 - Parcel 302E
I Location I Material Identification Physical 10 I Quantity I Units I Sample # I Results I
!Garage ISheetrock Wall I 200 I Square Feet I 1Q' I None Detected I
North Entry Popcorn Textured Ceiling Material Ceiling 150 Square Feet 12ABC None DetectedTan Floor Paper Paper 150 Square Feet 23A None Detected2 x 4 Rough CeilinQ Tile Ceiling 1 Each 14' None DetectedSheetrock Ceiling 450 Square Feet 1Q' None DetectedBlown In Insulation Ceiling 150 Sauare Feet 24' None Detected
Kitchen 2 2 x 4 Rough Ceiling Tile Ceiling 15 Each 14A None Detected2 x 4 Pinhole Ceiling Tile Ceiling 2 Each 15A None DetectedTan Linoleum wI tan adhesive 125 Square Feet HABC None DetectedTan Adhesive on tan linoleum 125 Square Feet 18ABC None DetectedSheetrock Walls and Ceiling 300 Square Feet 1QC None Detected
Living Room 2 12 x4 Rough Ceiling TileSheetrock
Water Closet 2 (WC2) /SheetrockGreen Sheetrock
CeilingWalis and Ceilin'
Walis and CeilingWalls and Ceiling
32450
15075
EachSquare Feet
Square FeetSquare Feet
14BC1QB
1Q'20ABC
None DetectedNone Detected
None DetectedNone Detected
Haliway 2 Sheetrock Walis and Ceiling 400 Square Feet 1Q' None Detected2 x 4 Rough Ceiling Tile Ceiling 4 Each 14' None DetectedLight Textured Ceiling Material Ceiling 125 Square Feet 13ABC None DetectedGrev Linoleum Floor 2 Square Feet 21A 21 % Chrvsotile
IBedroom 3 (BR3)~lSheetrock Walis and Ceiling =r m
425 I Square Feet I 1QA I None Detected I
Bedroom 4 (BR4) 2 x 4 Batwing Ceiling Tile Ceiling 21 Each 16ABC None DetectedSheetrock Walis and Ceiling 100 Square Feet 1Q' None DetectedWindow Caulk 1 Each 22A None Detected
IUtility Room IBlown In Insulation Ceiling I 2 I Square Feet I 24A I None Detected I
Exterior Roof ShingleRoof Tarpaper
15001500
Square FeetSquare Feet
25A26A
None DetectedNone Detected
,. ;; This result is inferred as consistent with an analyzed sample of the same material from another area.Page 2 of 2
Mn/DOT TH 101 - Parcel 302E
ill CHAIN-Of-CUSTODY RECORD
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'D~... ;", .. l location
18c... I AdL!v·cs ) 1 i/J/1'
'''' ill lfJ"w~le.~rs 61Z51f1 ~~oc/C..'T..C
Irv7Jf/11A I /1 I-M~~';...1 (
Ie, c. I 1/ K/~?-..., I
1/ ',':/7d,/// /_~/v
:J.()/J 1=s:1~ T-L I' I \ II II I I I /lbwr.s~ Wc.~?-b13 1;;,rl.U\ .~LncJ( T";.( I \ I ~ II I I I I I /
j;Jlffd
:J..f)C 1~~/r-c I \ I \ I \ I I I I I(9.-rA- I%:~t~~~:z I I I \ I \I I I I I I'J-M lo;~2JJ~Uu..lk I V I J I ~J I I II I
I:/f/Y;Jf;?kmfvjif)
Gener.ill Comments: Total Number 01 Containers
Relinquished by· Relinquished by:
Company·
Company: Company: Company:
Rec.eived by: Received by Relinquished by:
Company:~C Company:
0 ... .&Y/bd'/C:¥~ 10"e Date:~
ill CHAIN-OF-CUSTODY RECORD
3585 Lexington Avenue NorthSuite 15051. Paul, MN 55126651-766-9811651-766-9822
IprOject Manager:~~ ITurn Request
Project Name: TJllo·f Normal: !X'-'-__~_
Samp'e< SIgnature" OJ. _ rJj~/")
IHSC Project No Noi-:'-7-D5"-1 Mrr:L.(3o')..G
Project Location / t,MO 5 3rc<,sl-I'J.E.
Ji/
Number
fFJ
Laboratory
Sample
7/J!)~i~
7J1!)
Received
Sample Condition
Comments
Sample Condilon as
Chilled YES J NO
Sealed YES I NO
en ~L:;a:;b;;.,;,;N;,:a:.:.m:.:.e:'::'- -1Qj LAB USE ONLYcB ~L:;a:.b;.;..p,;,r;,OJI,;"e;,:c;;,I,;,N;,;O;,;" ..., -l<: r -ro()
I
I
°l~g~ --III 0. U.c ~.!.
E u·",a:
"Z
I
v
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~
I
'S" .£ I Analysis Requested§:Q::i~"'~- 0:gS- "'"' .- .o.~ ~- 0. -" ~.;r~E•"'
13 Ix
V Iv
OatefTime Sampled
I
"if
t-/h%~
Other _
Rush: _
Page: (p of (~
/UO
/.",..-7"
, I
Samp-re ldcal::>n Description
~.;-w,'/Jfy~"-t.~,_ r;, r;,.<:M.t:.L.C""
/
1"-'"
1l1-sJ.ol-::; -6;Hl(7~ 11 Q&>','fV? />I
1..--: ..,f" I. r JJP~oE"Sh/~ U--
Sample 10
-;2i)!t
2c/A-
73ft-
7(P/1
"7/
"'\
/General Comments: Total Number of Containers
RelinqUished by: Relinquished by: Relinquished by:
Company: Company:
Received b Received by: Relinquished by:
Company:~,
Company: Company:
O"e dPJP-~ Date: Date:
LEAD IN PAINT RESULTSPARCEL302E
16610 S3,d STREET NORTHEAST
ROGERS, MINNESOTA
IHSC PROJECT NUMBER MOS-20S.1
Paint LeadMethod
Sample illDate
Sample DescriptionSample Concentration
Reporting
Collected Location Limit(mg/kg*) (mglkg*)
302E-Pbl 4-19-06Green Window Trim Exterior
Exterior <1000 1000North Side
302E-Pb2 4-19-06East Exterior Red Window
Exterior 100 450Trim
*mglkg milligrams of lead per kilogram of surface material, which is equivalent to part per million (ppm).
The Minnesota Pollution Control Agency's (MPCA) threshold for lead containing paint is 5,000 parts permillion (ppm).
The Occupational Safety and Health Administration (OSHA) has no minimum threshold of lead in paint,therefore, when working with paint that has detectable levels of lead, the provisions of the OSHA standard1929.62 would apply.
- 1 -
Interpoll Laboratories, Inc.4500 Ball Road NE
Circle Pines, MN 55014-1819Tel: 763-786-6020
Fax: 763-786'7854www.interpoll-Iabs.com
May 10,2006
IHSC3585 Lexington Av., N., Suite 150St. Paul, MN 55126
Attention: Amy Buckley
LABORATORY REPORT:IHSC PROJECT:
SAMPLES COLLECTED:SAMPLES RECEIVED:
#22911#M05-205.1 Parcel 302E
April 19, 2006May 2,2006
LaboratoryLog Number
SampleIdentification
MOLSample Type (mg/kgl
RL(mg/kgl
Total Leada
(mg/kgl QUAL
22911-01
22911-02
302E-Pb1, Green Window TrimExterior North Side Paint Chips 200 1000 < 1000
302E-Pb2, East ExteriorRed Window Trim Paint Chips 90 450 100
Method Blank 10 50 < 50
J
Respectfully submitted,
Gregg W. Holman, ManagerChemistry Department
GWH/cgMOL = method detection limitRL = reporting limitQUAL = qualifier< = less thanJ = a reported value which is equal to or greater than the method detection limit (MOL), but less than orequal to the reporting limit (RL).
aThe samples were analyzed by EPA Method SW-846, 6010B on 5/8/06.
All analyses were performed using EPA or other recognized methodologies.All units are on an "as received" basis unless otherwise indicated. MN #027-003-148
/\1'1 L:OUAL OPP()fTf!.Jl'-J!TY FfvlPLOYEj,~
() \
0'?--
3585 Lexington Avenue North'
ill Suite 150
CHAIN-OF-CUSTODY RECORD SI. Paul, MN 55126651-766-9811651-766-9822
IHSC Project No: fA ')t; -20~, I ~rCl.J)01.(. Page: / of (~ .
Analysis Requested Lab Name: J-yt-L n'.(/ / (; bS-~
..2.~
Project Manager: .1 f'hAI'.Jd.r; V~Q. '" LAB USE bNLY~
Turn Request =- ~. '"Project Name: / It Inr I
NormaL ~-", c:
,:o.~
'" Lab Project No,..:;. -'(3 ::=. c:-~Rush: ~ 0 Sample Conditon as-.
P,oj,c, local;on, )t,(,.(() S3r~AJ.# ,<:)tJ" , U
Other: .~ g - Received Laboratory- 0
)0 ~~. -
" a ~
~;; '" a.w Chilled YES / NO Sample0 ..c • •
Sampler Signature: / J.M",,- <"~ E Eu ,-u •
Sealed YES I NO Number•
N",,,,
~ "S,ample 10 ' , Sample(locatif'l Description DalefTime Sampled Z Sample Condition
" Comments
3fJU-fb l &,~ k/;~(P 70'\'...- c.;(/q!Oc. 6 X r a &'1. vI --j-vo' J Ilbdi.. S.'VL. I
;}o2£-fJh1-.~f 4xf-u;.lor Rut.. f.(ft'1 fat. 6 y: (/,JJ1;tk;'; r;,~ , - I,
,
, ,
,
>
G,nm'Co,;,'m,n" (~/1~LJ- Ar.J fj/A ~R(~" lA?/ r'"<::;,,JA I'd-... I. Total Number of Containers
R,lin,u;,h,d by/')M c"Jj;f:;-yJ ! R~linqJshed by: Relinquished by·
Comp.ny ~LLI:: C (/It:;/rII.. Company· Company:
Received by: \ t \ ..A- Rec.eived by Relinquished by
Comp.ny lII--.-\..----r. DO I I Company Company: .._.-
D... ~I 't-10b If- f3S Dale" Date:
Appendix II16610 53rd Street Northeast
Structure Location & Floor Plan
26,0'
~
MAIN FLOOR
38.0'
~BBRl
X1A X28
3CXBR2
X2C
26,O't 19A4B ~ClJ4 X4A ;7A lC
14.0' ~A LIVING ROOM 1
~A X18X10A
FAMILYROOM 1
PbHALLWAY 1
12.0'
WEST ENTRY
NO SCALE
NORTHENTRY
22.0'14,0' GARAGE
26.0'LEGEND:
1BX BULKSAMPLE lOCATION
o Pb1 LEAD PAINT SAMPLE LOCATION
24.0'
STATE PROJECT NUMBER: 8608,21TH 101
BUILDING MAlERIALS SURVEY
PARCEL NO: 302E16610 S3RD STREET NORTHEAST
ROGERS, MINNESOTAPROJECT NO:
MOS·20S,302 mINDUSTRIAL HYGIENEDRAWN BY, SERVICES CORPORATIONDH
'22~, BASEMENTXt9A L~~~A6
BR3 X'
@lA 3A~16BX~
20 X S<\ HALLWAY 120C • U20A cmc X24A38.0' 138 38,0'
Xt:C X17B/18B X'4CX14A
UViNGX15A
ROOM 2KITCHEN 2 X14B
X17CIl8C 19BX==4
'4,0'
17A/18A
Appendix III16610 53'd Street Northeast
LicensesMDH Inspectorls License/s
Copies of Analytical Laboratory Accreditationls
iWh!teSeartike,flANoi1Augusf31,2005. . .E)(aminatlonDate:!.A,UgtJst31;2Q05:· .
ia~ Stat~ En:ironm~ntal,Dd .l' 0 Box. 645, RiceLake,wi 54868
(800/254;98JI' . . .
>>>=-11. .Certijh;ateNo.:-5LM083T0501IR Expiration Date.: August31, '2006
.-' .,' " . '.. '. ,.' . -",'" ..,.. ",.".,' '. -'.' .. '."' .
..'.'. . .: :ThisJs to .certify that .:' :'
. . .. Amy BLJ¢k!ey.. . '. '.''ha~aitendedand successfullycompl?tedan .
' ·.yfSBESTOSTNSPEC'/'lJlt ".·:···REFRESllERTR.AiNlNGCOURSE·. '.
...... : :....... ··..permitt2dby < ....< ... the State ofMinnesOtaundetMi~~eSQtakules4620:3702to 46203722
'.:' ".........•.........•.... .....·..o,:;u:1 77Jeetsthe.~equireme~tsof· :' , .' '.'
•.•. ~'''(on-?O.of'''''lJ.Ofth'Tdx'''$"b,tO.n'.;Cdntrol A't(l'SCA) ., .·">0'~I7:~j
'))1(.'&4 ~.
, . . ... ..... ~ ~~ous MATERI.4l$ At ..1:. 0'- .. fAA fA\)"('" . . -VV"C
~.&~\~ . . .' t1,~~.'.'" . .'~~ . . . ~ .
~~~efGm~1Y_'__is designated as a
Certified Hazardous Materials Manager
v\.imuthfJ
~.. ''/;}'9!Il
. ----.- .... -~" .. --_.. ..' .. DArf ' ..
---. J11..__:.._ ..NO
9I~?!;~_~~~!~tmVED!' _TOR.
·.S/!. ;J>w(/l. ,•.l\I.
111(/l
~<3d.~ ;0<1>
Expiration Date, August 18. 2006
Z -C/:l:to,m mO(/)01~. .•.<1'.•....."".~\~....•:l<.A!.ili.~ ... >. .' .". i:~,- ,,,,cc; :~-i$ ,:.. ':,f}!: ;;:::1 dlfi~ ", .... ",:;;;0,,"
-;j{~~ ~~".~~,
."'"":.,. -~ ~.; Q-a 5" Z. »lA, i'o <"" Q):r :J ''''' G?I,tl',-" ..;;:. 1lI""'-'" - it> ItJ Y' .01'c'<' m"ili'.',~,!!!.~ -"'0ll,. . _ •.",- m m'~' &(-'o.'J OCb:< 8,',.,; ...i:i"," 0 0~. :;0'"
~
g ~t)!r~~~~
~~~J
~l
Traini.ng lnsfru{;:r.=
This is to certify thatEric L. Hjort
has attended an4 sticcessjillly completed an
ASBE8TOSLNSPECTORlfEFRESHERfil.;J.INING COURSE
flenfjitted bytkeState oflvJinnesota Ulule,.A1i1~~(jrota>Rules 4620.3702 to 4620.3722
. . and meetstlfefeq1liremems ofSection 206 ofTitIe II ofthe Tb¥icp'.Substances Cafltrol..4ct (TSCA)
con.du.t:ted by
Lake States Env.ironmental, Ltd."" m
White Bear Lake,iVJNon Augusf 18, 2i)05Examination Date: August 18,2005
Certificate No.' 5LM081805031R
1.4ke Siaies EJIvironmenlal, LtdP. 0 Box 645. Rice Lake, Wt54868(800) 254-9811
z ·~";::";;".II9 ~,::!~:g.;.;~: g~Q7. ~:[' :-
~ii.l.l:ii~~~...·~.ic:', :p('l'O,:~.'_-::-'(W' t1) ~.' .....,
r'i'f~il!£$~-.,J." ~ Q .~..""N ;:0 ,.;.;.
oer
'"
.[Examination Datfi.: MarQh3,2006
ThiSts to certify that
J6hri ?JJJ1 Ha$tings'has atten{Je4alqdsu,cceysfidlycompletffdan
. .' ASBESTOS INSPECTORINITIAL"'T'ElAININGCiJURSE
. ' ... ' ' ... ' . ..... ..·pennittedbY· '.' - .... '.' .... . 'theSta.te ofMinnesqta under MimJesota Rules 46203702 to 46203722 ..
. . ','. . . (l!idmeets thej-equire'mentso{ .' .' .. Secti9n206 ofTitle II ofthe 'toxi';~Ltbstaneesqonl;olAct (TSCA). .' . . conducted by . . .' .
..Lake·.Stiltes·.·El1it:irt1nmel1tal,.Ltd.. '.' tn-;-" " .
AlBA Bulk Asbestos Program - Individual Lab Results
.t!.QJn.e.
Page I of 1
Total Penalty POinlS 0p
Round Status PProgram Stalus
0) 4244
NONE (0)NONE (0)NONE (0)
OlHR ( 100)NONE (0)NONE ( 0)
0
Amerlun Indu.trlal HygIene Allol;latlonBuill. AlIb8llo8 Ana'vtlul TeelIng Plog/an"
Re.ults of Round A65-4051/1612.008
Susan M. GrtlbbfAmy J. BuckleyIndustrial Hygiene Services Corporation Laborotory 10 Number3565 Lel(lnglon Avenue Nolth 102840Suile 15051. Paul. MN 55126
lOI Designalion\Sample to Numbers A) 79:55 6)7322 C) 6877
Analysis Results from Laboratory Number 102840Asbestos (0A.) CHRY ( .) AMOS (3) TREM ( 2)
NONE ( 0) NONE (0) NONE ( 0)NONE (0) NONE (0) NONE (0)
Oltler Flbrous Malerials ('Yo) FBGL IRA FBOL (93) OTHR ( 2)NONE (0) NONE (0) NONE (01
NonfjbrotJs Malerial (%) MICA ( 75) QTHR ( ') MICA ( 53)Penalty Points Assessed 0 0 0
Analysis Resulls from Reference laboralory OileAsbesll),$ ("to) CHRy (7 ) AMOS (. ) TREM (' )
Olt'ler Fibrous Mateoah. ('!o) FBGl (80 )CELL (1)
Nonfjbrous MaiMer (0/0) MICA (45 ) QTHR (15 ) ACID (72 )ACiD (45 ) MlCA (25)
Analysis ResulLs tj(}m Reference Laboralory TwoAsbestos (%) CHRY (. ) AMOS (' ) TREM (2)
CHRY (TRA)Olher Fibrous Millerials ('Yo) FBGL (52 )
Nonllbrous Malenal (%) OTHR (96 ) OTHR (15) ACID (68 )MICA (30 )
Acceptable QuanlitaOQfl Range (%) CHRY [fRA-12) AMOS [fRA-8 ) TREM [fRA-3 )
OTHR
OTHR
(100)
(100 I
SummaI)' or Rasulls from all LabOratoriesType One AsbeslosType One MeanType Two Asbestos.Type Two MeallType ThfU AsbestosType Thrae Mean
Olher ASbestos TypesReporteQ In Sample
ACTN"'AclinolileAMOS=AmosileANTH;Anlhophyt~te
CHRY
"ACTN. AMOS. TREM
CHRY=ChrysoOleCRQC=CroddolileTREM-Tremolile
AMOS'.2
ACTN, ANTH, CHRY,
CELL"CeNulosoF8GL;Fiberglass/Mlneral WoolSYNT""Synlhclic
TREM3.•
ACTN, AMOS, ANTH.CHRY
ACIO" aciQ,sQluble traclion, ir.ctu"ing bul nollimiled 10. calctle,gypsum, QoIomile, magnesite, hydlomaQfleslte, anhyQrite, ilndoouanileMICA-Micaceous MaterialOTHR=Othar
Round Slalus; P-Pass
Program Stalus' P;PloliCieM
F;Fail TE '"' TempOlsrily Excused
NP-NonproflCiel'll NA =Not Applicable
MlcroanalVtlcal Science~ I Environmental and IndustrIal Sciences Oivhiilon I RTI Inlernatlonalj AIHA
httn·//nuhlic.rti.org/aiha/reoort indiv.cfm?R=A65-405&P=A65 1116/2006
03/28/2006 13:45 FAX 7637867854 Interpoll Laboratories~vv,
Environmental Labora/ory Certification ProgramScope ofCertification
THIS LISTING OF CERTIFIED FIELDS OF TESTING MUST BEACCOMPANIED BY CERTIFICATE NUMBER: 10314AA
Stat, Labontory ID: 027·00)·148 EPA Lab Cod" MN00059 Expiration Date: AprU 13.2006
INTERPOLL LADORATORIES, INC.4500 BaD Road N.E.Circle Pines, MN 55014Pbone 763-786-6020
Resource Conservation and Recovery Program
A.alyt. M.thod Mllltrix
~i, EPA 60108 Solid &lid Chemical Mlleri.h
"",,", EPA 6020 Noo-potAble Water
Arsenic EPA (iOleB Non-potable Wlttr
Alxttic EPA 6020 Solid &lid ehemiul Mtlcrilh
BullllJ\ EPA 6020 Solid IUld ClKmical Materillf
BlriWD fiPA 60108 Solid and Chemic., Materilll
Bariwn EPA 6020 Noo-poubll: Wiler
BlriwTl EPA 6010B Non-pola.blc Wllu
CNlmill/Tl EPA 6Ol0 Solid and Chemic.l M&lcrl-ah
Cadmium EPA 6010B NO'G1'Otlblc W.ler
CUtnium EPA 60108 Solid ltId Chcmiul Mtterll!J
Cadmium EPA 6020 Non.~blc Waler
Chromium EPA 6020 Solid I.lld Chemic..1M'\l~rials
Ctuvcni~ EPA 6010 Non.polable W.ler
Cbrorniwn. EPA 6010B ,Noft.palab!e W.ler
Cnrom,ilJlrI EPA 60108 Solid Vld Chemical MI\(rillli
Copper EPA 602.0 Solid U1d Chemical Mllenah
"-' EPA6010B Solid.,.(l Qlem,-cil Maltn.l,
COOP" EPA 6010 Non-potlblc. Wiler
C._ EPA 60108 f'lon·poUlblc WUCT
l<.o6 EPA 6020 Solid and Chemical M.lLrial~
l<.o6 EPA 6010B Solid ahd Chemical Mllerial~
l<.o6 EPA 6020 Non·potable Watu
Wd EPA 60108 Noo·potAble W,tCT
M=W)' BPA 6010 Solid. ead Chcmietl Millen'"
M=rt EPA 6020 Non·~le W.ler
Molybdenum EPA 6020 Solid WId Ctlcmic.' Mlllen.ls
Molybdenum EPA 60108 Non.poUlblc. W.ter
Page 11 ofl7 11J01/04 OZ7-00}-I<l'