June 10, 2015 Ms. Marsha Smith, P.E. Campus Facilities...

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June 10, 2015 Ms. Marsha Smith, P.E. University of Missouri Campus Facilities – Project Management 111 General Services Building Columbia, Missouri 65211 RE: Asbestos Survey Report - Sub-Basement, Mechanical Room and Associated Tunnel System Memorial Student Union (North Wing) Columbia, Missouri SCI No. 2015-0112.25 MU Project # CP151421 Dear Ms. Smith: INTRODUCTION SCI Engineering, Inc. (SCI) is pleased to submit this report of the analytical test results for samples of suspect asbestos-containing materials (ACMs) collected during the survey performed on May 19, 2015 for the sub-basement, mechanical room and associated tunnel system. The purpose of this survey was to identify ACMs in accessible areas of the sub-basement and tunnel system at the above-referenced site. This survey is intended to satisfy the requirements for the asbestos National Emission Standard for Hazardous Air Pollutant (NESHAP) for demolition and renovation. It is not intended to be used for Occupational Safety and Health Administration (OSHA) compliance. ASBESTOS SURVEY Twenty-one samples were collected from within the surveyed area. Of these 21 samples, 9 individual samples/layers were analyzed using a positive stop procedure. These samples were analyzed by Polarized Light Microscopy (PLM). Of the 9 samples/layers analyzed, 6 were found to contain asbestos. Photographic documentation of the materials sampled is provided in Appendix A, maps indicating the approximate location of ACMs is provided in Appendix B, and the analytical test results and chain-of- custody documentation are provided in Appendix C. The results of the laboratory analyses are summarized in Table 1, below. Table 1 – Summary of Analytical Test Results Sample Number Material Location Material Description Result Category 1a Sub-Basement, Mechanical Room & Tunnels Small Mudded Fittings (on 1” to 4” diameter piping) 75% Chrysotile Friable 1b Not Analyzed 1c Not Analyzed

Transcript of June 10, 2015 Ms. Marsha Smith, P.E. Campus Facilities...

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June 10, 2015 Ms. Marsha Smith, P.E. University of Missouri Campus Facilities – Project Management 111 General Services Building Columbia, Missouri 65211 RE: Asbestos Survey Report - Sub-Basement, Mechanical Room and Associated Tunnel System Memorial Student Union (North Wing)

Columbia, Missouri SCI No. 2015-0112.25 MU Project # CP151421

Dear Ms. Smith: INTRODUCTION SCI Engineering, Inc. (SCI) is pleased to submit this report of the analytical test results for samples of suspect asbestos-containing materials (ACMs) collected during the survey performed on May 19, 2015 for the sub-basement, mechanical room and associated tunnel system. The purpose of this survey was to identify ACMs in accessible areas of the sub-basement and tunnel system at the above-referenced site. This survey is intended to satisfy the requirements for the asbestos National Emission Standard for Hazardous Air Pollutant (NESHAP) for demolition and renovation. It is not intended to be used for Occupational Safety and Health Administration (OSHA) compliance. ASBESTOS SURVEY Twenty-one samples were collected from within the surveyed area. Of these 21 samples, 9 individual samples/layers were analyzed using a positive stop procedure. These samples were analyzed by Polarized Light Microscopy (PLM). Of the 9 samples/layers analyzed, 6 were found to contain asbestos. Photographic documentation of the materials sampled is provided in Appendix A, maps indicating the approximate location of ACMs is provided in Appendix B, and the analytical test results and chain-of-custody documentation are provided in Appendix C. The results of the laboratory analyses are summarized in Table 1, below.

Table 1 – Summary of Analytical Test Results

Sample Number Material Location Material Description Result Category

1a Sub-Basement, Mechanical

Room & Tunnels Small Mudded Fittings

(on 1” to 4” diameter piping)

75% Chrysotile

Friable 1b Not Analyzed

1c Not Analyzed

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Ms. Marsha Smith, P.E. 2 June 10, 2015 University of Missouri SCI No. 2015-0112.25

Table 1 – Summary of Analytical Test Results (continued)

Sample Number Material Location Material Description Result Category

2a Sub-Basement, Mechanical

Room & Tunnels Pipe Insulation

(1” to 4” diameter )

40% Chrysotile 5% Amosite

Friable 2b Not Analyzed

2c Not Analyzed

3a Sub-Basement, Mechanical

Room & Tunnels Medium Mudded Fittings

(on 5” to 8” diameter piping)

65% Chrysotile

Friable 3b Not Analyzed

3c Not Analyzed

4a Sub-Basement, Mechanical

Room & Tunnels Pipe Insulation

(5” to 8” diameter)

65% Chrysotile

Friable 4b Not Analyzed

4c Not Analyzed

5a Sub-Basement, Mechanical

Room & Tunnels

Large Pipe Insulation Mag Block

(8”+ diameter piping)

40% Chrysotile

Friable 5b Not Analyzed

5c Not Analyzed

6a Sub-Basement, Mechanical

Room & Tunnels

Large Pipe Insulation Suspect Air Cell

(8”+ diameter piping)

None Detected

-- 6b None Detected

6c None Detected

7a Sub- Sub-Basement, Mechanical Room &

Tunnels

Large Mudded Fittings (8”+ diameter piping)

75% Chrysotile

Friable 7b Not Analyzed

7c Not Analyzed

DEMOLITION/RENOVATION RECOMMENDATIONS According to the Missouri Department of Natural Resources (MDNR), any friable or potentially friable ACM equal to or greater than 260 linear feet or 160 square feet is classified as a regulated ACM (RACM) and must be removed prior to demolition or renovation which would significantly damage the material. The thermal system insulation (TSI) (i.e. pipe insulation and mudded pipe fittings) found throughout the sub-basement, mechanical room and associated tunnels were identified as being a friable ACM. Therefore, these materials must be removed prior to the commencement of any demolition or renovation activities which will disturb these materials. In general, the TSI was in good condition, with only a few, small, localized areas where damaged was observed. In the areas where damaged was observed, portions of the damaged TSI was laying on the underlying piping and concrete floor. Damaged TSI was limited to the tunnel system. The quantities provided below in Table 2 and Table 3 represents the ACM observed within the sub-basement, mechanical room and tunnel system and does not include the piping and associated fittings that extend into the south wing of the Memorial Student Union or to the floors above the sub-basement level. Observable piping and pipe fittings originating from the sub-basement that connect to other floors will be addressed in a separate report.

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Ms. Marsha Smith, P.E. 3 June 10, 2015 University of Missouri SCI No. 2015-0112.25 With the exception of the large diameter pipe insulation represented by Samples 6a, 6b and 6c, all TSI sampled/observed during survey activities was identified as being ACM. Although survey activities did not determine the extent of the non-ACM TSI, SCI estimates the quantity of large insulation represented by Samples 6a, 6b and 6c is approximately 25% (250 linear feet). The Occupational Safety & Health Administration also has regulations (29 CFR Parts 1910 et al, Occupational Exposure to Asbestos, August 10, 1994) regarding removal of asbestos-containing materials which must be followed. COSTS FOR ABATEMENT As previously mentioned, the pipe insulation and associated mudded fittings should be removed from the structure prior to commencement of renovation activities that may impact the materials. Summarized in the table below are estimated abatement costs for the ACM identified during SCIs survey activities. The estimates outlined below included removal, transport, and disposal of the materials as an asbestos waste by a Missouri-licensed asbestos abatement contractor. These abatement estimates do not include fees associated with the oversight by a third party consultant, including but not limited to perimeter and clearance air monitoring.

Table 2 – Tunnel System Summary of Abatement Costs

Material Location Material Description Approx. Quantity

Tunnel System

1” to 4” Diameter Pipe Insulation 1,600 lf

Small Mudded Fittings (on 1” to 4” pipe) 365

5” to 8” Diameter Pipe Insulation 900 lf

Medium Mudded Fittings (on 5” to 8” pipe) 100

Large Pipe Insulation (8”+ pipe) 600 lf1

Large Mudded Fittings (on 8”+ pipe) 25 lf – linear feet 1- Includes approximately 150 lf of non-ACM TSI

Table 3 – Sub-Basement & Mechanical Room Summary of Abatement Costs

Material Location Material Description Approx. Quantity

Sub-Basement & Mechanical Room

1” to 4” Diameter Pipe Insulation 750 lf

Small Mudded Fittings (on 1” to 4” pipe) 175

5” to 8” Diameter Pipe Insulation 325 lf

Medium Mudded Fittings (on 5” to 8” pipe) 40

Large Pipe Insulation (8”+ pipe) 400 lf1

Large Mudded Fittings (on 8”+ pipe) 25 lf – linear feet 1- Includes approximately 100 lf of non-ACM TSI REPORTING The Demolition and Renovation form, which has been filled out to the extent possible by SCI, is provided in Appendix D. The remaining information must be completed by you.

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Ms. Marsha Smith, P.E. 4 June 10, 2015 University of Missouri SCI No. 2015-0112.25 This report, as well as the completed EPA Notification of Demolition and Renovation form, must be submitted to the MDNR as follows:

• MDNR, Air Pollution Control, PO Box 176, Jefferson City, MO, 65102, Mr. Todd Schneiders

It should be noted that following submittal of the notification form, there is a ten day waiting period before demolition, renovation, or abatement activities can begin. CERTIFICATION A copy of the Missouri Asbestos License is contained in Appendix E for Mr. Douglas Ell and Mr. Greg Landers who conducted the asbestos survey and prepared the asbestos survey report. SCI's asbestos survey entailed visually assessing accessible areas only. If any other suspect asbestos materials are discovered during demolition or renovation, please contact SCI, and we will make arrangements for assessment of these materials. Areas behind walls, under subfloors and above fixed ceilings are considered non-accessible. If this report is to be used for bidding purposes for asbestos abatement, SCI recommends the contractor visit the site to verify all conditions and quantities. SCI appreciates the opportunity to be of service to you on this project, and we look forward to working with you in the future. Please contact us if you have any questions or comments regarding the information provided. Respectfully, SCI ENGINEERING, INC. Gregory W. Landers Douglas J. Ell Missouri State Certified Asbestos Inspector Missouri State Certified Asbestos Inspector Certificate Number 7011121014MOII17484 Certification Number 7011072011MOII15399 Trey L. Coad, CHMM Senior Project Manager GWL/DJE/TLC/hmm Enclosure \\2015-0112 Memorial Student Union Survey-MU\25\Sub-Basement Report\15-0112.25 - Sub-Basement Report.doc

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Appendix A

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Photo 1. Sample SB-001A and SB-002A collected from TSI on piping.

Photo 2. Sample SB-003A collected from TSI on piping.

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Photo 3. Sample SB-004A collected from TSI on piping.

Photo 4. Sample SB-005A collected from TSI on piping.

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Photo 5. Sample SB-006A collected from TSI on piping

Photo 6. Sample SB-007A collected from TSI on piping

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Appendix B

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BASE

D ON

UND

ATED

PLAN

PROV

IDED

ELEC

TRON

ICAL

LY O

N 6/0

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5BY

THE U

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RSIT

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MIS

SOUR

I,DI

MENS

IONS

AND

LOCA

TION

S ARE

APP

ROXI

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E; A

CTUA

L MAY

VARY

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WIN

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ALL

NOT B

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D OU

TSID

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CON

TEXT

OF T

HE R

EPOR

T FOR

WHI

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WAS

GEN

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GENE

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/LEG

END

06/2015DATE2015-0112.25

JOB NUMBER

DJECHECKED BYDRAWN BY RCV

ACM

IN TU

NNEL

S

MEMO

RIAL

STUD

ENT U

NION

- NOR

TH W

ING

COLU

MBIA

, MISS

OURI

PROJ

ECT N

AME

1 FIGURE

1"-4" PIPE (1600 LF) / 365 MUDDED FITTINGS5"-8" PIPE (900 LF) / 100 MUDDED FITTINGS

8"+ PIPE (600 LF) / 25 MUDDED FITTINGS

UNEXCAVATEDMECHANICAL ROOMN000A

MECHANICAL ROOMN000B

ELECTRICALMECHANICAL ROOM

N000C

SCALE 1" = 25'

®

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BASE

D ON

UND

ATED

PLAN

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IDED

ELEC

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IONS

AND

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06/2015DATE2015-0112.25

JOB NUMBER

DJECHECKED BYDRAWN BY RCV

ACM

IN SU

B-BA

SEME

NT

MEMO

RIAL

STUD

ENT U

NION

- NOR

TH W

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COLU

MBIA

, MISS

OURI

PROJ

ECT N

AME

2 FIGURE

UNEXCAVATED

MECHANICAL ROOMN000A

MECHANICAL ROOMN000B

ELECTRICALMECHANICAL ROOM

N000C

SB-001ASB-002A

SB-003ASB-004ASB-005A

x4

FEED AND RETURNS FOR RADS.FEED AND RETURNS FOR RADS.FEED AND RETURNS FOR RADS.FEED AND RETURNS FOR RADS.

x2

SB-006C

SB-006ASB-006A

LARGEFITTING

SB-007CSB-005C

SB-003CSB-004C

x3

SB-007B

SB-004BSB-005B

SB-001BSB-002BSB-003BSB-006B

FIRE DOOR

MAGAIRCELL

x3

FIBERGLASS

SCALE 1" = 15'

®

1" - 4" PIPES (750 LF) / 175 MUDDED FITTINGS

5" - 8" PIPES (325 LF) / 40 MUDDED FITTINGS

8"+ PIPES (400 LF) / 25 MUDDED FITTINGS

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Appendix C

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SanAir Technologies Laboratory, Inc.1551 Oakbridge Drive, Suite B, Powhatan, VA 23139804.897.1177 Toll Free: 888.895.1177 Fax: 804.897.0070Web: http://www.sanair.com E-mail: [email protected]

Name:Address:

SCI Engineering Inc130 Point West BlvdSt Charles, MO 63301

Project Number:P.O. Number:

Project Name:

2015-0112.25Memorial Student Union - Sub-BasementMU Project #CP151421

Collected Date:Received Date:

Report Date:Analyst:

5/19/20155/22/2015 10:20:00 AM6/1/2015 5:48:12 PMVaughan, Nathaniel

Asbestos Bulk PLM EPA 600/R-93/116Stereoscopic Components Asbestos

SanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-001A / 15014559-001 White 25% Other 75% ChrysotileSub-Basement & Tunnels, Small FibrousMudded Fitting Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-001B / 15014559-002 Not AnalyzedSub-Basement & Tunnels, SmallMudded Fitting

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-001C / 15014559-003 Not AnalyzedSub-Basement & Tunnels, SmallMudded Fitting

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-002A / 15014559-004 White 55% Other 40% ChrysotileSub-Basement & Tunnels, 1"-4" Fibrous 5% AmositePipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-002B / 15014559-005 Not AnalyzedSub-Basement & Tunnels, 1"-4"Pipe Insulation

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-002C / 15014559-006 Not AnalyzedSub-Basement & Tunnels, 1"-4"Pipe Insulation

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-003A / 15014559-007 White 35% Other 65% ChrysotileSub-Basement & Tunnels, Med. FibrousMudded Fitting Heterogeneous

15014559SanAir ID Number

FINAL REPORT

Certification

Signature: Reviewed:

Date: 6/1/2015 Date: 6/1/2015 Page 1 of 3

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SanAir Technologies Laboratory, Inc.1551 Oakbridge Drive, Suite B, Powhatan, VA 23139804.897.1177 Toll Free: 888.895.1177 Fax: 804.897.0070Web: http://www.sanair.com E-mail: [email protected]

Name:Address:

SCI Engineering Inc130 Point West BlvdSt Charles, MO 63301

Project Number:P.O. Number:

Project Name:

2015-0112.25Memorial Student Union - Sub-BasementMU Project #CP151421

Collected Date:Received Date:

Report Date:Analyst:

5/19/20155/22/2015 10:20:00 AM6/1/2015 5:48:12 PMVaughan, Nathaniel

Asbestos Bulk PLM EPA 600/R-93/116Stereoscopic Components Asbestos

SanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-003B / 15014559-008 Not AnalyzedSub-Basement & Tunnels, Med.Mudded Fitting

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-003C / 15014559-009 Not AnalyzedSub-Basement & Tunnels, Med.Mudded Fitting

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-004A / 15014559-010 White 35% Other 65% ChrysotileSub-Basement & Tunnels, 5"-8" FibrousPipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-004B / 15014559-011 Not AnalyzedSub-Basement & Tunnels, 5"-8"Pipe Insulation

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-004C / 15014559-012 Not AnalyzedSub-Basement & Tunnels, 5"-8"Pipe Insulation

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-005A / 15014559-013 White 60% Other 40% ChrysotileSub-Basement & Tunnels, Large FibrousPipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-005B / 15014559-014 Not AnalyzedSub-Basement & Tunnels, LargePipe Insulation

15014559SanAir ID Number

FINAL REPORT

Certification

Signature: Reviewed:

Date: 6/1/2015 Date: 6/1/2015 Page 2 of 3

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SanAir Technologies Laboratory, Inc.1551 Oakbridge Drive, Suite B, Powhatan, VA 23139804.897.1177 Toll Free: 888.895.1177 Fax: 804.897.0070Web: http://www.sanair.com E-mail: [email protected]

Name:Address:

SCI Engineering Inc130 Point West BlvdSt Charles, MO 63301

Project Number:P.O. Number:

Project Name:

2015-0112.25Memorial Student Union - Sub-BasementMU Project #CP151421

Collected Date:Received Date:

Report Date:Analyst:

5/19/20155/22/2015 10:20:00 AM6/1/2015 5:48:12 PMVaughan, Nathaniel

Asbestos Bulk PLM EPA 600/R-93/116Stereoscopic Components Asbestos

SanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-005C / 15014559-015 Not AnalyzedSub-Basement & Tunnels, LargePipe Insulation

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-006A / 15014559-016 Brown 85% Cellulose 15% Other None DetectedSub-Basement & Tunnels, Large FibrousPipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-006B / 15014559-017 Brown 85% Cellulose 15% Other None DetectedSub-Basement & Tunnels, Large FibrousPipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-006C / 15014559-018 Brown 85% Cellulose 15% Other None DetectedSub-Basement & Tunnels, Large FibrousPipe Insulation Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-007A / 15014559-019 White 25% Other 75% ChrysotileSub-Basement & Tunnels, Large FibrousMudded Fitting Heterogeneous

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-007B / 15014559-020 Not AnalyzedSub-Basement & Tunnels, LargeMudded Fitting

Stereoscopic Components AsbestosSanAir ID / Description Appearance % Fibrous % Non-Fibrous FibersSB-007C / 15014559-021 Not AnalyzedSub-Basement & Tunnels, LargeMudded Fitting

15014559SanAir ID Number

FINAL REPORT

Certification

Signature: Reviewed:

Date: 6/1/2015 Date: 6/1/2015 Page 3 of 3

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Appendix D

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STATE OF MISSOURI DEPARTMENT OF NATURAL RESOURCES

ASBESTOS NESHAP NOTIFICATION OF DEMOLITION AND RENOVATION

OPERATOR PROJECT NO. POSTMARK DATE RECEIVED NOTIFICATION NUMBER

I. TYPE OF NOTIFICATION

O – ORIGINAL C – CANCELLED R – REVISION, WRITE REVISION NUMBER ___ ______ II. FACILITY INFORMATION (IDENTIFY OWNER, REMOVAL CONTRACTOR, AND OTHER OPERATOR) OWNER NAME

ADDRESS

CITY

COUNTY

STATE

ZIP CODE

CONTACT

TELEPHONE NUMBER

ASBESTOS REMOVAL CONTRACTOR

ADDRESS

CITY

STATE

ZIP CODE

CONTACT

TELEPHONE NUMBER

TITLE

DEMOLITION CONTRACTOR

ADDRESS

CITY

STATE

ZIP CODE

CONTACT

TELEPHONE NUMBER

TITLE

III. TYPE OF OPERATION

D - DEMO O – ORDERED DEMO R – RENOVATION E – EMERGENCY RENOVATION IV. IS ASBESTOS PRESENT

YES NO LIST TYPE OF ASBESTOS MATERIAL(S) TO BE REMOVED

Thermal System Insulation (TSI) – Pipe Insulation and Mudded Fittings (Various Sizes) V. FACILITY DESCRIPTION (INCLUDE BUILDING NAME, NUMBER AND FLOOR OR ROOM NUMBER) BUILDING NAME

Memorial Student Union ADDRESS

518 Hitt Street CITY

Columbia COUNTY

Boone STATE

MO ZIP CODE

65201 SITE LOCATION

University of Missouri Campus BUILDING SIZE

93,000 sf NUMBER OF FLOORS

4 AGE IN YEARS

65 PRESENT USE

Student Union – Office Space, Dining & Multi-purpose PRIOR USE

NA VI. PROCEDURE, INCLUDING ANALYTICAL METHOD, IF APPROPRIATE, USED TO DETECT THE PRESENCE OF ASBESTOS MATERIAL. INCLUDE A COPY OF THE ASBESTOS INSPECTION.

Inspection with analysis by Polarized Light Microscopy (PLM) Inspection of non-friable organically bound (NOB) materials with analysis by Transmission Electron Microscopy (TEM) VII. APPROXIMATE AMOUNT OF ASBESTOS, INCLUDING: 1. REGULATED ACM (RACM) 2. CATEGORY I ACM 3. CATEGORY II ACM

RACM TO BE REMOVED

NONFRIABLE ASBESTOS MATERIAL TO BE REMOVED

NONFRIABLE ASBESTOS MATERIAL NOT TO BE REMOVED

CAT I CAT II CAT I CAT II

PIPES (LINEAR FEET) SURFACE AREA (SQUARE FEET) VOL. RACM OFF FACILITY COMPONENT (CUBIC FEET)

MO 780-1923 (5-05) PAGE 1 OF 2

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VIII. SCHEDULED DATES DEMO/RENOVATION (MM/DD/YY)

START: COMPLETE: IX. SCHEDULED DATES ASBESTOS REMOVAL (MM/DD/YY)

START: COMPLETE:

WEEKDAYS WORK HOURS

WEEKEND WORK HOURS

X. DESCRIPTION OF PLANNED DEMOLITION OR RENOVATION WORK, AND METHOD(S) TO BE USED

XI. DESCRIPTION OF WORK PRACTICES AND ENGINEERING CONTROLS TO BE USED TO PREVENT EMISSIONS OF ASBESTOS AT THE DEMOLITION AND RENOVATION SITE.

XII. WASTE TRANSPORTER ADDRESS CITY

STATE

ZIP CODE

CONTACT PERSON

TELEPHONE NUMBER

XIII. WASTE DISPOSAL SITE NAME LOCATION CITY

STATE

ZIP CODE

TELEPHONE NUMBER

XIV. IF DEMOLITION ORDERED BY A GOVERNMENT AGENCY, PLEASE IDENTIFY THE AGENCY BELOW NAME

TITLE

AUTHORITY

DATE OF ORDER (MM/DD/YY) INCLUDE A COPY OF THE ORDER.

DATE ORDERED TO BEGIN (MM/DD/YY)

XV. FOR EMERGENCY RENOVATIONS A. DATE AND HOUR OF EMERGENCY (MM/DD/YY) B. DESCRIPTION OF THE SUDDEN, UNEXPECTED EVENT

C. EXPLANATION OF HOW THE EVENT CAUSED UNSAFE CONDITIONS OR WOULD CAUSE EQUIPMENT DAMAGE OR AN UNREASONABLE FINANCIAL BURDEN

XVI. DESCRIPTION OF PROCEDURES TO BE FOLLOWED IN THE EVENT THAT UNEXPECTED ASBESTOS IS FOUND OR PREVIOUSLY NONFRIABLE ASBESTOS MATERIAL BECOMES CRUMBLED, PULVERIZED, OR REDUCED TO POWDER. Stop work and contact a licensed inspector.

XVII. I certify that an individual trained in the provisions of this regulation (40 CFR Part 61, Subpart M) will be on-site during the demolition or renovation and evidence that the required training has been accomplished by this person will be available for inspection during normal business hours (required 1 year after promulgation). SIGNATURE OF OWNER/OPERATOR DATE

XVIII. I Certify that the above information is correct. SIGNATURE OF OWNER/OPERATOR DATE

MO 780-1923 (5-05) REGULATED DEMOLITIONS: PLEASE ATTACH COPY OF ASBESTOS INSPECTION PAGE 2 OF 2