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HomeMy WebLinkAboutAntique Mall Asbestos Abatement S & R Environmental 1 | Page 5801 Logan Street Denver CO 80216 303-297-1645 Phone 303-297-1646 Fax www.srenvironmentalconsulting.com May 3, 2011 Jared Johnson Weston Solutions 355 S. Teller St. Suite 300 Lakewood, CO 80226 Cc: James Hester, Weston Solutions Dale Gibbs, Alpine Demolition RE: Asbestos Abatement and Environmental Project Oversight Antique Mall and Former Gas Station 7300, 7340 And 7350 West 44th Avenue Wheat Ridge, CO 80033 S & R Project Number: 011026 Dear Mr. Johnson, S&R Environmental Consulting, Inc. (S&R) is pleased to provide this close-out report on the project oversight and air sampling activities conducted following the abatement of asbestos- containing materials (ACM) from the buildings located at 7300, 7340 and 7350 West 44th Avenue, in Wheat Ridge, Colorado. S&R was onsite throughout the duration of the abatement project which lasted from March 15, 2011 through April 20, 2011. One additional site visit was conduct on April 26, 2011 to inspect the property during the final demolition portions of the project. S&R acted as the onsite project industrial hygiene consultant throughout the duration of the project. The following report includes details about the abatement activities, air sampling data and final clearance activities. EXECUTIVE SUMMARY Weston Solution Inc., (Weston) was seeking a professional environmental consulting company to provide project oversight in response to an abatement and demolition project at the addresses noted above. On March 15, 2011, abatement activities began on the removal of approximately 6,710 square feet of ACM which had to be removed prior to the demolition of the building. 2 | Page Alpine Demolition and Recycling (Alpine) was selected as the General Abatement Contractor (GAC), and proceeded with setup activities inside several work area throughout the property. The work areas were placed under primary containment, fitted with a three stage decon area, a two stage waste load-out and placed under negative pressure. Soon after, Alpine began gross removal abatement activities inside each work area. Finally, Alpine began final cleaning activities in the work areas in order to prepare them for a final visual inspection and final air clearances. Starting on March 15, 2011, Alex Green and/or Greg St. Louis of S&R were onsite to provide project oversight for the asbestos abatement work that was to be done. This involved assuring that all abatement procedures were done in accordance with the provisions of the State of Colorado Regulation 8. In addition, area and personal air monitoring was conducted during abatement activities in order to comply with Regulation 8 and OSHA procedures. The final visual inspection and final air clearances in the work area was performed on several dates throughout the project. The clearances were conducted by either Alex Green or Greg St. Louis, both certified and accredited as an Air Monitoring Specialist by the Environmental Protection Agency (EPA) and the State of Colorado (CDPHE). Laboratory analysis determined that all clearance samples were below the Maximum Allowable Asbestos Level (MAAL) of 0.01 fibers per cubic centimeter (f/cc). Following, the abatement activities and final air clearances, the work areas were cleared for tear down and re-occupancy by other personnel. The entire property was turned over to Alpine for demolition on April 20, 2011. 3 | Page INTRODUCTION S&R understands that Weston was seeking a professional environmental consulting company to provide project oversight and asbestos abatement clearances during this project. The air sampling and analysis was performed in accordance with the provisions of the State of Colorado Regulation Number 8 Part B – Asbestos (Reg 8). Asbestos abatement was performed by Alpine using personnel trained and certified to perform such work in the State of Colorado. S&R has prepared this report of findings based on the results of the air sampling analysis conducted throughout the duration of the project. SCOPE OF WORK S&R was on site and provided project oversight during asbestos abatement activities on this project. Six areas required asbestos abatement. The first work area was a bathroom in the former gas station that contained approximately 25 square feet of ACM vinyl flooring that was removed in a secondary enclosure. Since the amount of ACM was below the trigger levels of 260 square feet for a commercial building, a permit was not required for this work area. The first permitted work area, Work Area #1, contained approximately 310 square feet of popcorn ceiling texture with approximately 2,000 square feet of associated overspray on the soffit on the east side of the main room in the 7340 building. The second permitted work area, Work Area #2, contained approximately 300 square feet of sheet vinyl flooring in the kitchen of the 7350 building. Work Area #3 contained approximately 150 square feet of popcorn ceiling texture with approximately 500 square feet of associated overspray on the west side soffit and approximately 250 square feet of sheet vinyl flooring in an area north of the soffit of the 7350 building. Work Area #4 contained approximately 40 feet on the south side (structural) of the east exterior wall that contained ACM cementations masonry underlayment (block filler). Work Area # 5 contained the north side (non-structural) of the east exterior wall. A copy of the CDPHE Abatement Permits is included in Appendix J. S&R collected area air samples each day during the active abatement near each work area. Area samples were analyzed on site and compared to the Maximum Allowable Asbestos Level (MAAL) to ensure asbestos fibers were not migrating out of the containment. Areas typically monitored included the spaces adjacent to the decon chamber, the waste load-out and the negative air exhaust ports. Each area sample S&R collected was below the MAAL. S&R also collected personal air samples from select asbestos workers performing abatement to comply with OSHA regulations. Each personal sample S&R collected was below the permissible exposure limit (PEL) of 0.1 fibers per cc (f/cc) or excursion limit of 1.0 f/cc when the assigned protection factor of the worker’s respirator was included. At the conclusion of abatement in each permitted work area, S&R performed a visual inspection inside the work area. If the work area was determined to be free of dust and debris and the required ACM was removed, S&R proceeded to collect clearance air samples in accordance with 4 | Page Colorado Regulation 8. Each work area containment passed the final air clearances on the first attempt. Sample results for the area and clearance air monitoring are included in Appendix B and the personal air monitoring results are included in Appendix C. Initial Assessment and Development of the Project Design: S&R issued a report on January 31st, 2011, detailing our limited inspection of the building located at 7340 and 7350 West 44th Avenue. Prior to collecting any bulk samples, S&R reviewed the inspection report performed by HWS Consulting Group in 2008. S&R also inspected the former gas station and reviewed the Higgins and Associates asbestos inspection report of the former gas station dated April 2010. S&R relied on both reports for the identification of ACM materials. If S&R discovered materials that were not sampled in either report S&R sampled the suspect material. However, S&R did not take confirmatory samples of materials that were described in the other consultants’ reports. Copies of the HWS report is included in Appendix G and the Higgins report is in Appendix H. Following review of the sample data, S&R compiled a Project Design which detailed how the containments should be set up including how many negative air machines were required in each containment, where the decontamination units should be set up and where waste load out should be. S&R collected three additional bulk samples of the CMU wall on the east side and three samples of sheet vinyl flooring that was discovered following the removal of some carpet in the 7340 building. The CMU samples were obtained from the northeast corner of the building, from the east face of the north wall. All three samples were none-detected for asbestos. The sheet vinyl samples did contain asbestos and a change order was issued for the removal of the material. A copy of the laboratory reports and chain of custodies are included in Appendix A of this report. S&R also monitored the construction of the asbestos containments and the abatement activities to ensure the abatement was done in accordance with Reg 8. Prior to the start of active abatement, S&R inspected each containment to ensure it met the requirements of Reg 8 and that Alpine understood the work practices required inside that containment. All containments were set up in accordance with all necessary procedures. CONTRACTOR QUALIFICATIONS S&R reviewed all of Alpine’s state issued asbestos certifications, medical evaluation certifications and respirator fit tests, and determined that all workers involved in the project were certified to perform tasks associated with an Asbestos Worker. All Asbestos Workers were fit tested and qualified to wear half-face respirators. State certified Supervisors were also onsite at all times throughout the project. S&R examined the Supervisor’s records, training documents and certifications as well to ensure they were able to act as the onsite supervisor. In addition, S&R submitted their own copies of their asbestos certifications, medical certifications and respiratory fit tests in order to act as the onsite industrial hygienist and air monitoring specialist. Finally, all certifications and records from both parties were examined to ensure that they were 5 | Page valid during the project. Please refer to the Worker/Supervisor/AMS Certifications in Appendix D for more information. Visual Inspections and Final Air Monitoring: The work area at 7300 West 44th Ave. was less than 260 square feet and therefore did not require a permit in accordance with Reg 8. The removal of asbestos containing vinyl flooring was performed under secondary containment and a visual inspection was conducted following abatement. The visual inspection ascertained that the area was clean and free of debris. All waste generated during the abatement was disposed of as Asbestos Containing Waste Material (ACWM). Based on our visual inspection, the bathroom work area was cleared for tear down on March 16, 2011. The remaining five work areas, one in building 7350 West 44th Avenue and four at 7340 West 44th Avenue were permitted abatement projects. A copy of the Permit is included in Appendix J. Following completion of abatement work, a visual inspection was conducted in each work area. The visual inspection ascertained that the area was clean and free of dust or debris. All waste generated during the abatement was disposed of as Asbestos Containing Waste Material (ACWM). Following the visual inspection of the work area, an S&R inspector collected final air samples to clear each work area. Using aggressive sampling techniques, a total of five (5) clearance samples were collected inside each contained each work area. High volume air- sampling pumps were placed within the work area and a volume of at least 1200 liters of air were passed through each of the five standard 0.8um Phase Contrast Microscopy (PCM) filter cassettes. ANALYTICAL PROCEDURES All air samples collected for the project and field blanks were analyzed utilizing the NIOSH 7400 method for PCM analysis. All clearance samples were read by either Alex Green or Greg St. Louis at S&R’s mobile laboratory that was set up on site. S&R’s AIHA laboratory ID number is 190843. Both Alex Green and Greg St. Louis have passed both the NIOSH 582 Equivalent Course and the current Proficiency Analytical Testing (PAT) Program for analyzing Phase Contrast Microscopy (PCM) samples. RESULTS The US Environmental Protection Agency (EPA), the Occupational Safety and Health Administration (OSHA), and the State of Colorado (CDPHE) considers an abatement project complete if the final air samples are below the Maximum Allowable Asbestos Level (MAAL) of 0.01 fibers per cubic centimeter (f/cc). Laboratory analysis determined all clearance samples had fiber concentrations below 0.01 f/cc. Following each clearance sample analysis, results were verbally communicated to both the Alpine Supervisor and Weston’s on site Project Manager. AREA SAMPLES 6 | Page S&R collected area air samples adjacent to the containment locations during active abatement activities. These samples were then analyzed and compared to the MAAL, to ensure asbestos was not migrating out of the containment. A high volume sampling pump was calibrated to collect between four and six liters of air per minute for each area sample. Area samples were generally set up in the morning and the filter cassette was changed at the lunch break. The samples were collected at the end of each work shift. PERSONAL SAMPLES S&R collected personal samples from select workers during the abatement inside the containments. The personal samples were collected to gather exposure data from the workers most likely to be overexposed inside the containment because of the task they were performing. The personal samples were analyzed onsite, and copies of the results were posted and turned- over to the shift supervisor. AIR SAMPLING RESULTS SUMMARY Clearance Air Samples Work Area 1: 7340 W. 44th Ave.- East Soffit- Acoustic Ceiling Sample Number Date Area Results (f/cc) 026-32411-FC 1 3/24/2011 Work Area #1 - Near Decon/WLO 0.005 f/cc 026-32411-FC 2 3/24/2011 Work Area #1 - Near North Viewport 0.004 f/cc 026-32411-FC 3 3/24/2011 Work Area #1 - Central 0.005 f/cc 026-32411-FC 4 3/24/2011 Work Area #1 - Central 0.003 f/cc 026-32411-FC 5 3/24/2011 Work Area #1 - Near NAMs 0.004 f/cc Work Area 2: 7350 W. 44th Ave.- Kitchen- Sheet Vinyl Flooring Sample Number Date Area Results (f/cc) 026-32411-C 1 3/25/2011 Kitchen Containment 0.003 f/cc 026-32411-C 2 3/25/2011 Kitchen Containment 0.003 f/cc 026-32411-C 3 3/25/2011 Kitchen Containment 0.003 f/cc 026-32411-C 4 3/25/2011 Kitchen Containment 0.003 f/cc 026-32411-C 5 3/25/2011 Kitchen Containment 0.006 f/cc Work Area 3: 7350 W. 44th Ave- West Soffit- Sheet Vinyl Flooring & Acoustic Ceiling Sample Number Date Area Results (f/cc) 026-32911-C-1 3/29/2011 Work Area #3 North end 0.003 f/cc 026-32911-C-2 3/29/2011 Work Area #3 Sheet Vinyl 0.002 f/cc 026-32911-C-3 3/29/2011 Containment Work Area #2 Sheet Vinyl 0.002 f/cc 026-32911-C-4 3/29/2011 Containment Work Area #2 Acoustic Ceiling 0.004 f/cc 7 | Page 026-32911-C-5 3/29/2011 Containment Work Area #2 Acoustic Ceiling BDL Work Area 4: 7340 W. 44th Ave.- East Wall- South Side- CMU Sample Number Date Area Results (f/cc) 026-41111-C-1 4/11/2011 E Wall – S End Containment 0.002 f/cc 026-41111-C-2 4/11/2011 E Wall – S End Containment 0.002 f/cc 026-41111-C-3 4/11/2011 E Wall – S End Containment 0.003 f/cc 026-41111-C-4 4/11/2011 E Wall – S End Containment BDL 026-41111-C-5 4/11/2011 E Wall – S End Containment 0.002 f/cc Work Area 5: CMU - 7340 W. 44th Ave. East Wall- North Side- Hand Demo CMU Sample Number Date Area Results (f/cc) 026-41911-C-1 4/19/2011 Work Area #4 CMU 0.003 f/cc 026-41911-C-2 4/19/2011 Work Area #4 CMU 0.002 f/cc 026-41911-C-3 4/19/2011 Work Area #4 CMU 0.002 f/cc 026-41911-C-4 4/19/2011 Work Area #4 CMU 0.002 f/cc 026-41911-C-5 4/19/2011 Work Area #4 CMU BDL Area Air Samples Sample Number Date Area Results (f/cc) 026-32211-OWA-1 3/22/11 Containment #1 near waste load out 0.004 026-32211-OWA-2 3/22/11 Containment #1 near negative air machines 0.008 026-32311-A1 3/23/11 Containment # 1 near waste load out 0.003 026-32311-A2 3/23/11 Containment #1 near negative air machines 0.004 026-322311-A3 3/23/11 Containment #1 near waste load out 0.007 026-32311-A4 3/23/11 Containment # 1 near negative air machines 0.005 026-32411-A1 3/24/11 Containment # 2 near waste load out 0.007 026-32411-A2 3/24/11 Containment #2 near negative air machines 0.006 026-32411-A3 3/24/11 Containment #2 near negative air machines 0.002 026-32411-A4 3/24/11 Containment #2 near waste load out 0.003 026-32811-OWA-1 3/28/11 Containment # 3 near waste load out 0.004 026-32811-OWA-2 3/28/11 Containment #3 near negative air machines 0.003 026-32811-OWA-3 3/28/11 Containment #3 near waste load out 0.002 026032811-OWA-4 3/28/11 Containment # 3 near negative air machines 0.004 026-33111-A1 3/31/11 Containment #4 near waste load out 0.005 026-33111-A2 3/31/11 Containment #4 near waste load out 0.006 026-4111-A1 4/1/11 Containment #4 outdoors near negative air exhaust 0.004 8 | Page Sample Number Date Area Results (f/cc) 026-4111-A2 4/1/11 Containment #4 near waste load out 0.007 026-4111-A3 4/1/11 Containment #4 outdoors near negative air exhaust 0.004 026-4111-A4 4/1/11 Containment #4 near waste load out CBR 026-4411-A1 4/4/11 Containment #4 near waste load out CBR 026-4411-A2 4/4/11 Containment #4 outdoors near negative air exhaust BDL 026-4411-A3 4/4/11 Containment #4 near waste load out 0.005 026-4411-A4 4/4/11 Containment #4 outdoors near negative air exhaust BDL 026-4511-A1 4/5/11 Containment #4 near waste load out 0.002 026-4511-A2 4/5/11 Containment #4 outdoors near negative air exhaust BDL 026-4511-A3 4/5/11 Containment #4 outdoors near negative air exhaust 0.003 026-4511-A4 4/5/11 Containment #4 near waste load out 0.004 026-4611-A1 4/6/11 Containment #4 near waste load out 0.005 026-4611-A2 4/6/11 Containment #4 outdoors near negative air exhaust 0.003 026-4611-A3 4/6/11 Containment #4 outdoors near negative air exhaust 0.005 026-4611-A4 4/6/11 Containment #4 near waste load out 0.007 026-4711-A1 4/7/11 Containment #4 near waste load out 0.003 026-4711-A2 4/7/11 Containment #4 outdoors near negative air exhaust 0.004 026-4711-A3 4/7/11 Containment #4 near waste load out 0.002 026-4711-A4 4/7/11 Containment #4 outdoors near negative air exhaust 0.004 026-4811-A1 4/8/11 Containment #4 near waste load out 0.002 026-4811-A2 4/8/11 Containment #4 outdoors near negative air exhaust BDL 026-4811-A3 4/8/11 Containment #4 near waste load out 0.003 026-4811-A4 4/8/11 Containment #4 outdoors near negative air exhaust BDL 026-41211-A1 4/12/11 Containment #5 outdoors near negative air exhaust 0.005 026-41211-A2 4/12/11 Containment #5 near water heater 0.004 026-41211-A3 4/12/11 Containment #5 near water heater 0.003 026-41211-A4 4/12/11 Containment #5 outdoors near negative air exhaust 0.001 026-41311-A1 4/13/11 Containment #5 near water heater 0.004 026-41311-A2 4/13/11 Containment #5 outdoors near negative air exhaust BDL 026-41311-A3 4/13/11 Containment #5 near water heater 0.006 026-41311-A4 4/13/11 Containment #5 outdoors near negative air exhaust BDL 9 | Page Sample Number Date Area Results (f/cc) 026-41411-A1 4/14/11 Containment #5 near water heater 0.004 026-41411-A2 4/14/11 Containment #5 near water heater 0.003 026-41511-A1 4/15/11 Containment #5 outdoors near negative air exhaust BDL 026-41511-A2 4/15/11 Containment #5 near water heater BDL 026-41511-A3 4/15/11 Containment #5 outdoors near negative air exhaust BDL 026-41511-A4 4/15/11 Containment #5 near water heater 0.003 026-41811-A1 4/18/11 Containment #5 near water heater BDL 026-41811-A2 4/18/11 Containment #5 outdoors near negative air exhaust 0.002 026-41811-A3 4/18/11 Containment #5 near water heater CBR 026-41811-A4 4/18/11 Containment #5 outdoors near negative air exhaust BDL 026-41911-A1 4/19/11 Containment #5 near water heater 0.004 026-41911-A2 4/19/11 Containment #5 outdoors near negative air exhaust BDL Personal Air Samples Sample Number Date Personal Sample/Task Sample Time Results (f/cc) 026-32211-IWA-1 3/22/2011 Mario Terrones / Scraping Acoustic Ceiling Abatement 30min. 0.119 026-32211-IWA-2 3/22/2011 James Miller / Scraping Acoustic Ceiling 303min. 0.026 026-32311-P-1 3/23/2011 Rogelio Rhiz-Alcantas Sr. / Vinyl Flooring Removal 30min. 0.078 026-33111-P-1 3/31/2011 Andre Williams / Jackhammer block filler (CMU) 114min. 0.038 026-33111-P-2 3/31/2011 Andre Williams / Jackhammer block filler (CMU) 203min. CBR 026-33111-P-3 3/31/2011 Carlos Zamora / Jackhammer block filler (CMU) 30min. 0.049 026-4511-P-1 4/5/2011 Jorge Hernandez / Jackhammer block filler (CMU) 221min. 0.018 026-4511-P-2 4/5/2011 Jorge Hernandez / Jackhammer block filler (CMU) 30min. 0.047 026-4511-P-3 4/5/2011 Jorge Hernandez / Jackhammer block filler (CMU) 170min. CBR 026-41211-P-1 4/12/2011 James Miller / Chisel Block (CMU) 129min. 0.022 026-41211-P-2 4/12/2011 James Miller / Chisel Block (CMU) 30min. 0.024 026-41211-P-3 4/12/2011 James Miller / Chisel Block (CMU) 155min. 0.011 CBR=Could not be read BDL=Below Detection limit 10 | Page REGULATED BUILDING MATERIALS S&R observed Alpine demolition remove fluorescent light bulbs and light ballasts from the overhead lights. Older fluorescent light bulbs may contain mercury vapor. The light ballasts may contain polychlorinated biphenyls. Additionally, several light bulbs were found in the building areas that were suspect mercury vapor lights. If the fluorescent bulbs contained green end caps they were disposed of as construction debris. If the bulbs did not have the green caps they were collected, stock piled, and placed in 55-gallon drums for disposal. Alpine brought a bulb crusher to the site to reduce the volume of waste in each 55-gallon drum. The bulb crusher mounted on top of a standard 55-gallon drum and would grind the glass bulbs to reduce the volume in the drum. The bulbs were fed into the crusher one at a time. A HEPA vacuum attached to the grinder collected dusts or mists that were generated during the grinding. Additionally, the worker feeding the bulbs into the grinder was wearing a P-100 half face respirator. Mercury ampoules that were found in the thermostats in the building were placed in the drums with the ground light bulbs. The ballasts that were suspected of containing PCB’s were collected in separate 55-gallon drums. Alpine reported that Clean Harbors would collect the drums and dispose of the waste appropriately. Waste manifests for the disposal of the asbestos, mercury and PCB’s were not available at the time of production of this report. The waste manifests will be made available by Alpine once they are issued and finalized. CLOSING COMMENTS S&R appreciates the opportunity to assist with your asbestos sampling and oversight needs. If you have any questions regarding this report of findings, please do not hesitate to call us at (303) 297-1645. CONFIDENTIALITY This communication including all contents and attachments are confidential and may be subject to privilege. Sincerely, Greg St. Louis Project Manager S&R ENVIRONMENTAL CONSULTING, INC. 11 | Page Attachments Appendix A: Supplemental Bulk Sample Laboratory Results & Chain of Custodies Appendix B: Area Air Monitoring Results Appendix C: Personal Air Monitoring Results Appendix D: Certifications Appendix E: Waste Manifests Appendix F: S&R Consultant Daily Logs Appendix G: HWS Environmental Inspection Report Appendix H: Higgins and Associates Asbestos Report 7300 W. 44th Ave Appendix I: Jefferson County Inspection Report Appendix J: Permits Appendix K: Project Pictures Appendix A Supplemental Bulk Sample Laboratory Results & Chain of Custodies Page 1 of 2 Laboratory Code: RES Subcontract Number: NA Laboratory Report: RES 210066-1 Project # / P.O. # 011026 Project Description: Rick Block RES 210066-1 Sincerely, Anita Grigg Robert R. Workman Jr. Bethany Nichols March 23, 2011 Analyst(s): _________________________ Paul D. LoScalzo Wenlong Liu Michael Scales Adam Humphreys is the job number assigned to this study. This report is considered highly confidential and the sole property of the customer. Reservoirs Environmental, Inc. will not discuss any part of this study with personnel other than those of the client. The results described in this report only apply to the samples analyzed. This report must not be used to claim endorsement of products or analytical results by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full, without written approval from Reservoirs Environmental, Inc. Samples will be disposed of after sixty days unless longer storage is requested. If you have any questions about this report, please feel free to call 303-964-1986. Jeanne Spencer Orr President Dear Customer, Reservoirs Environmental, Inc. is an analytical laboratory accredited for the analysis of Industrial Hygiene and Environmental matrices by the National Voluntary Laboratory Accreditation Program (NVLAP), Lab Code 101896-0 for Transmission Electron Microscopy (TEM) and Polarized Light Microscopy (PLM) analysis and the American Industrial Hygiene Association (AIHA), Lab ID 101533 - Accreditation Certificate #480 for Phase Contrast Microscopy (PCM) analysis. This laboratory is currently proficient in both Proficiency Testing and PAT programs respectively. Reservoirs Environmental, Inc. has analyzed the following samples for asbestos content as per your request. The analysis has been completed in general accordance with the appropriate methodology as stated in the attached analysis table. The results have been submitted to your office. S & R Environmental 5801 Logan St. Ste 200 Denver CO 80216 44th And Wads. P: 303-964-1986 F: 303-477-4275 5801 Logan Street, Suite 100 Denver, CO 80216 Page 1 of 2 1-866-RESI-ENV www.reilab.com Page 2 of 2 TA B L E P L M B U L K A N A L Y S I S , P E R C E N T A G E C O M P O S I T I O N B Y V O L U M E RE S J o b N u m b e r : Cl i e n t : Cl i e n t P r o j e c t N u m b e r / P . O . : Cl i e n t P r o j e c t D e s c r i p t i o n : Da t e S a m p l e s R e c e i v e d : An a l y s i s T y p e : Tu r n a r o u n d : Da t e A n a l y z e d : Cl i e n t Non N o n - Sa m p l e Su b A sbesto s Fibrous Nu m b e r Ph y s i c a l P a r t F i b r o u s C o m p o n e n t s De s c r i p t i o n ( % ) Mi n e r a l V i s u a l Component s (%) Es t i m a t e ( % ) (%) . SV F - 0 1 EM 7 1 6 3 4 7 A O r a n g e / b r o w n s h e e t v i n y l w / g r a y f i b r o u s ba c k i n g & c r e a m r e s i n o u s m a t e r i a l 10 0 Ch r y s o t i l e 4 0 10 5 0 SV F - 0 2 EM 7 1 6 3 4 8 A O r a n g e / b r o w n s h e e t v i n y l w / g r a y f i b r o u s ba c k i n g 10 0 Ch r y s o t i l e 3 0 565 SV F - 0 3 EM 7 1 6 3 4 9 A O r a n g e / b r o w n s h e e t v i n y l w / g r a y f i b r o u s ba c k i n g 10 0 Ch r y s o t i l e 3 0 565 RE S E R V O I R S E N V I R O N M E N T A L , I N C . NV L A P L a b C o d e 1 0 1 8 9 6 - 0 TD H L i c e n s e d L a b o r a t o r y # 3 0 - 0 1 3 6 ID N u m b e r L A Y E R La b PL M , S h o r t R e p o r t 2 H o u r A sb e s t o s C o n t e n t RE S 2 1 0 0 6 6 - 1 Ma r c h 2 3 , 2 0 1 1 01 1 0 2 6 44 t h A n d W a d s . S & R E n v i r o n m e n t a l Ma r c h 2 3 , 2 0 1 1 ND = N o n e D e t e c t e d TR = T r a c e , < 1 % V i s u a l E s t i m a t e Tr e m - A c t = T r e m o l i t e - A c t i n o l i t e No t e : F u r t h e r a n a l y s i s b y T E M i s r e c o m m e n d e d f o r o r g a n i c a l l y b o u n d m a t e r i a l ( i . e . f l o o r t i l e ) if P L M r e s u l t s a r e < 1% . _______Data QA Page 1 of 2 Laboratory Code: RES Subcontract Number: NA Laboratory Report: RES 211047-1 Project # / P.O. # 011026 Project Description: Greg St. Louis RES 211047-1 Sincerely, Anita Grigg Robert R. Workman Jr. Bethany Nichols April 11, 2011 Analyst(s): _________________________ Paul D. LoScalzo Wenlong Liu Michael Scales Adam Humphreys is the job number assigned to this study. This report is considered highly confidential and the sole property of the customer. Reservoirs Environmental, Inc. will not discuss any part of this study with personnel other than those of the client. The results described in this report only apply to the samples analyzed. This report must not be used to claim endorsement of products or analytical results by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full, without written approval from Reservoirs Environmental, Inc. Samples will be disposed of after sixty days unless longer storage is requested. If you have any questions about this report, please feel free to call 303-964-1986. Jeanne Spencer Orr President Dear Customer, Reservoirs Environmental, Inc. is an analytical laboratory accredited for the analysis of Industrial Hygiene and Environmental matrices by the National Voluntary Laboratory Accreditation Program (NVLAP), Lab Code 101896-0 for Transmission Electron Microscopy (TEM) and Polarized Light Microscopy (PLM) analysis and the American Industrial Hygiene Association (AIHA), Lab ID 101533 - Accreditation Certificate #480 for Phase Contrast Microscopy (PCM) analysis. This laboratory is currently proficient in both Proficiency Testing and PAT programs respectively. Reservoirs Environmental, Inc. has analyzed the following samples for asbestos content as per your request. The analysis has been completed in general accordance with the appropriate methodology as stated in the attached analysis table. The results have been submitted to your office. S & R Environmental 5801 Logan St. Ste 200 Denver CO 80216 44th & Wadsworth P: 303-964-1986 F: 303-477-4275 5801 Logan Street, Suite 100 Denver, CO 80216 Page 1 of 2 1-866-RESI-ENV www.reilab.com Page 2 of 2 TA B L E P L M B U L K A N A L Y S I S , P E R C E N T A G E C O M P O S I T I O N B Y V O L U M E RE S J o b N u m b e r : Cl i e n t : Cl i e n t P r o j e c t N u m b e r / P . O . : Cl i e n t P r o j e c t D e s c r i p t i o n : Da t e S a m p l e s R e c e i v e d : An a l y s i s T y p e : Tu r n a r o u n d : Da t e A n a l y z e d : Cl i e n t Non N o n - Sa m p l e Su b A sbesto s Fibrous Nu m b e r Ph y s i c a l P a r t F i b r o u s C o m p o n e n t s De s c r i p t i o n ( % ) Mi n e r a l V i s u a l Component s (%) Es t i m a t e ( % ) (%) . 02 6 - 4 1 1 1 1 - C M U - 0 1 EM 7 2 3 3 0 9 A G r a y c i n d e r b l o c k 3 0 ND 0 1 0 0 B B l u e / m u l t i - c o l o r e d p a i n t w / w h i t e r e s i n o u s pl a s t e r 70 ND 0 1 0 0 02 6 - 4 1 1 1 1 - C M U - 0 2 EM 7 2 3 3 1 0 A W h i t e p l a s t e r 2 0 ND 0 1 0 0 B G r a y c i n d e r b l o c k 3 0 ND 0 1 0 0 C B l u e / m u l t i - c o l o r e d p a i n t w / w h i t e r e s i n o u s pl a s t e r 50 ND 0 1 0 0 02 6 - 4 1 1 1 1 - C M U - 0 3 EM 7 2 3 3 1 1 A B l u e / m u l t i - c o l o r e d p a i n t w / w h i t e r e s i n o u s pl a s t e r 35 ND 0 1 0 0 B G r a y c i n d e r b l o c k 6 5 ND 0 1 0 0 RE S E R V O I R S E N V I R O N M E N T A L , I N C . NV L A P L a b C o d e 1 0 1 8 9 6 - 0 TD H L i c e n s e d L a b o r a t o r y # 3 0 - 0 1 3 6 ID N u m b e r L A Y E R La b PL M , S h o r t R e p o r t 2 H o u r A sb e s t o s C o n t e n t RE S 2 1 1 0 4 7 - 1 Ap r i l 1 1 , 2 0 1 1 01 1 0 2 6 44 t h & W a d s w o r t h S & R E n v i r o n m e n t a l Ap r i l 1 1 , 2 0 1 1 ND = N o n e D e t e c t e d TR = T r a c e , < 1 % V i s u a l E s t i m a t e Tr e m - A c t = T r e m o l i t e - A c t i n o l i t e No t e : F u r t h e r a n a l y s i s b y T E M i s r e c o m m e n d e d f o r o r g a n i c a l l y b o u n d m a t e r i a l ( i . e . f l o o r t i l e ) if P L M r e s u l t s a r e < 1% . _______Data QA Appendix B Area Air Monitoring and Final Air Clearance Results 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/CC) OWA-1 1,455 100 11 14.01 0.002 0.004 OWA-2 1,356 100 22 28.03 0.002 0.008 Comments: All area samples below MAAL of 0.01 f/cc. AIHA Laboratory ID: 190843 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 info@srenvironmentalconsulting.com 026-32211 Project Number: Project Address: Sample Date: Sampled By: Date Analyzed: Analysis Type: Sample Prefix: 011026 7340 W 44th Ave Weatridge, CO 80033 3/22/2011 Greg St.Louis & Alex Green 3/22/2011 PCM NIOSH 7400 BDL = Below Detection Limit ND = None Detected Page: Sample Location Containment #1 - Near Waste Load OContainment #1 - Near NAM 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/CC) A-1 2,662 100 17 21.66 0.001 0.003 A-2 2,736 100 22 28.03 0.001 0.004 A-3 1,153 100 17 21.66 0.002 0.007 A-4 1,104 100 11.5 14.65 0.002 0.005 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Area pumps off from 11:15AM to 12:20PM (65 Minutes) All area samples below MAAL. BDL = Below Detection Limit ND = None Detected Sample Prefix:026-32311- Page: Sample Location North End of Containment #1 South End of Containment #2 Kitchen Containment - Outside D /WLOKitchen Containment - Near NAM Sampled By:Alex Green Date Analyzed:3/23/2011 Analysis Type:PCM NIOSH 7400 Sample Date:3/23/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,390 100 21 26.75 0.002 0.007 A-2 1,361 100 16.5 21.02 0.002 0.006 OWA-1 1,210 100 5.5 7.01 0.002 0.002 OWA-2 1,219 100 7.5 9.55 0.002 0.003 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Kitchen Near NAM Kitchen Near Decon Kitchen Containment - Near NAM Sampled By:Alex Green Date Analyzed:3/24/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-32411- Page: Sample Location Kithchen Containment - Decon/WLO Sample Date:3/24/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Final Clearance 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) FC 1 1,526 100 14.5 18.47 0.002 0.005 FC 2 1,538 100 14 17.83 0.002 0.004 FC 3 1,550 100 17 21.66 0.002 0.005 FC 4 1,556 100 10 12.74 0.002 0.003 FC 5 1,572 100 12.5 15.92 0.002 0.004 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Sample Date:3/24/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Work Area #1 - Near North Viewport Sampled By:Alex Green Date Analyzed:3/24/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-32411- Page: Sample Location Work Area #1 - Near Decon/WLO Work Area #1 - Central Work Area #1 - Central Work Area #1 - Near NAMs Final Clearance 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) C 1 1,450 100 9 11.46 0.002 0.003 C 2 1,519 100 9 11.46 0.002 0.003 C 3 1,490 100 8.5 10.83 0.002 0.003 C 4 1,480 100 9.5 12.10 0.002 0.003 C 5 1,529 100 17.5 22.29 0.002 0.006 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Sample Date:3/25/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Kitchen Containment Sampled By:Greg St.Louis Date Analyzed:3/25/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-32511- Page: Sample Location Kitchen Containment Kitchen Containment Kitchen Containment Kitchen Containment 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) OWA-1 1,378 100 12 15.29 0.002 0.004 OWA-2 1,301 100 8.5 10.83 0.002 0.003 OWA-3 1,111 100 3.5 4.46 0.002 0.002 OWA-4 1,032 100 8 10.19 0.003 0.004 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Area pumps off from 11:15AM to 12:20PM (65 Minutes) All area samples below MAAL. Near Loadout/Decon Near NAM Near NAM Sampled By:Greg St.Louis Date Analyzed:3/28/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-32811- Page: Sample Location Near Loadout/Decon Sample Date:3/28/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 Final Clearance 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) C-1 1,335 100 7 8.92 0.002 0.003 C-2 1,335 100 6 7.64 0.002 0.002 C-3 1,335 100 5 6.37 0.002 0.002 C-4 1,335 100 9.5 12.10 0.002 0.004 C-5 1,308 100 2 2.55 0.002 BDL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: BDL=Below Detection Limit Sample Date:3/29/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Containment Work Area #2 Sheet V Sampled By:Greg St.Louis Date Analyzed:3/29/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-32911- Page: Sample Location Containment Work Area #2 Sheet V Containment Work Area #2 Sheet V Containment Work Area #2 Acoustic CContainment Work Area #2 Acoustic C 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,222 100 12 15.29 0.002 0.005 A-2 1,177 100 14 17.83 0.002 0.006 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Between Loadout & Decon Sampled By:Greg St.Louis Date Analyzed:3/31/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-33111- Page: Sample Location Between Loadout & Decon Sample Date:3/31/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,050 100 7.5 9.55 0.003 0.004 A-2 1,147 100 15.5 19.75 0.002 0.007 A-3 1,050 100 9 11.46 0.003 0.004 A-2 1,167 100 CNR NA 0.002 NA #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All area samples passed. A-4 could not be read due to too much debris on filter. Outside near NAM Exhuast Near Decon/Loadout Near Decon/Loadout Sampled By:Greg St.Louis & Jolene Dickerson Date Analyzed:4/1/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4111- Page: Sample Location Outside near NAM Exhuast Sample Date:4/1/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,601 100 CBR NA 0.002 CBR A-2 1,724 100 2 2.55 0.002 BDL A-3 1,079 100 12 15.29 0.002 0.005 A-2 1,142 100 1 1.27 0.002 BDL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: CBR =Could not Be Read , BDL = Below Detection Limit Between Decon & Loadout Outside Near NAM Exhaust Outside Near NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/4/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4411- Page: Sample Location Between Decon & Loadout Sample Date:4/4/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,651 100 6 7.64 0.002 0.002 A-2 1,762 100 0 0.00 0.002 BDL A-3 1,401 100 8.5 10.83 0.002 0.003 A-2 1,196 100 10.5 13.38 0.002 0.004 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: BDL=Below Detection Limit Between Loadout & Decon Outside Near NAM Exhaust Outside Near NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/5/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4511- Page: Sample Location Between Loadout & Decon Sample Date:4/5/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,038 100 11 14.01 0.003 0.005 A-2 1,138 100 8 10.19 0.002 0.003 A-3 1,261 100 13.5 17.20 0.002 0.005 A-2 1,151 100 16 20.38 0.002 0.007 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Outside by NAM Exhaust Between Loadout & Decon Room Outside by NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/6/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4611- Page: Sample Location By Loadout & Decon Room Sample Date:4/6/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,092 100 7 8.92 0.002 0.003 A-2 1,159 100 10.5 13.38 0.002 0.004 A-3 1,151 100 5 6.37 0.002 0.002 A-2 1,435 100 12.5 15.92 0.002 0.004 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Between Loadout & Decon By NAM Exhaust By NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/7/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4711- Page: Sample Location Between Loadout & Decon Sample Date:4/7/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,391 100 8 10.19 0.002 0.003 A-2 1,618 100 3 3.82 0.002 0.001 A-3 1,020 100 7 8.92 0.003 0.003 A-2 1,214 100 2.5 3.18 0.002 0.001 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Between Loadout & Decon Outside Near NAM Exhaust Outside Near NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/8/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-4811- Page: Sample Location Between Loadout & Decon Sample Date:4/8/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Final Clearance 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) C-1 1,277 100 4.5 5.73 0.002 0.002 C-2 1,326 100 5 6.37 0.002 0.002 C-3 1,323 100 7.5 9.55 0.002 0.003 C-4 1,300 100 3 3.82 0.002 0.001 C-5 1,346 100 5.5 7.01 0.002 0.002 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Sample Date:4/11/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO E Wall - S End Containment Sampled By:Greg St.Louis Date Analyzed:4/11/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41111- Page: Sample Location E Wall - S End Containment E Wall - S End Containment E Wall - S End Containment E Wall - S End Containment 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,398 100 13 16.56 0.002 0.005 A-2 1,283 100 9.5 12.10 0.002 0.004 A-3 1,171 100 6 7.64 0.002 0.003 A-2 1,178 100 2 2.55 0.002 BDL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: BDL=Below Detection Limit Near Water Heater NE Corner NAM Exhaust Near Water Heater Sampled By:Alex Green & Greg St.Louis Date Analyzed:4/12/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41211- Page: Sample Location NE Corner NAM Exhaust Sample Date:4/12/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyz ed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,555 100 9 11.46 0.002 0.003 A-2 1,605 100 2 2.55 0.002 BDL A-3 1,555 100 14 17.83 0.002 0.004 A-2 1,605 100 CBR NA 0.002 CBR #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: BDL=Below Detection Limit, CBR =Could not Be Read By Decon NE Corner by NAM Exhaust NE Corner by NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/13/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41311- Page: Sample Location By Decon Sample Date:4/13/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,208 100 9.5 12.10 0.002 0.004 A-2 961 100 5 6.37 0.003 0.003 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Near HW Heater Sampled By:Greg St.Louis Date Analyzed:4/14/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41411- Page: Sample Location Near HW Heater Sample Date:4/14/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/MM2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,645 100 3 3.82 0.002 BDL A-2 1,488 100 4 5.10 0.002 BDL A-3 826 100 2 2.55 0.003 BDL A-2 780 100 5 6.37 0.003 0.003 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: BDL=Below Detection Limit N Side NAM Exhaust Near Water Heater Near Water Heater Sampled By:Greg St.Louis Date Analyzed:4/15/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41511- Page: Sample Location N Side NAM Exhaust Sample Date:4/15/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,479 100 4.5 5.73 0.002 0.002 A-2 1,607 100 5 6.37 0.002 0.002 A-3 NA 100 CBR CBR "CBR A-2 1,498 100 2 2.55 0.002 BDL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: CBR=Could not Be Read, BDL=Below Detection Limit By Decon By NAM Exhaust N Side By NAM Exhaust N Side Sampled By:Greg St.Louis Date Analyzed:4/18/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41811- Page: Sample Location By Decon Sample Date:4/18/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) A-1 1,086 100 9 11.46 0.002 0.004 A-2 1,232 100 2 2.55 0.002 bdl #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: N Side NAM Exhaust Sampled By:Greg St.Louis Date Analyzed:4/19/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41911- Page: Sample Location Near Decon Sample Date:4/19/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Final Clearance 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) C-1 1,349 100 7 8.92 0.002 0.003 C-2 1,306 100 4.5 5.73 0.002 0.002 C-3 1,240 100 5 6.37 0.002 0.002 C-4 1,270 100 6 7.64 0.002 0.002 C-5 1,235 100 2 2.55 0.002 BDL #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: Sample Date:4/19/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO Work Area #4 CMU Sampled By:Greg St.Louis Date Analyzed:4/19/2011 Analysis Type:PCM NIOSH 7400 Sample Prefix:026-41911- Page: Sample Location Work Area #4 CMU Work Area #4 CMU Work Area #4 CMU Work Area #4 CMU Appendix C Personal Air Monitoring Results 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/CC) IWA-1 54 100 13 16.56 0.039 0.119 IWA-2 548 100 28.5 36.31 0.004 0.026 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All fiber concentrations were BDL after application of OSHA 's Assigned Protection Factor (APF = 10) for a half-face air perifying respirator (APR). BDL = Below Detection Limit ND = None Detected Page: Sample Location Mario Terrones - Scraping Acoustic C James Miller - Scraping Acoustic C 026-32211 Project Number: Project Address: Sample Date: Sampled By: Date Analyzed: Analysis Type: Sample Prefix: 011026 7340 W 44th Ave Weatridge, CO 80033 3/22/2011 Greg St.Louis & Alex Green 3/22/2011 PCM NIOSH 7400 AIHA Laboratory ID: 190843 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 info@srenvironmentalconsulting.com 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detectio n (F/cc) Fiber Concentration (F/cc) P-1 60.3 100 9.5 12.10 0.035 0.078 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All fiber concentrations were BDL after application of OSHA 's Assigned Protection Factor (APF = 10) for a half-face air perifying respirator (APR). BDL = Below Detection Limit ND = None Detected Sample Prefix:026-32311- Page: Sample Location Rogelio Rhiz-Alcantas Sr. - Vinyl F Sampled By:Alex Green Date Analyzed:3/23/2011 Analysis Type:PCM NIOSH 7400 Sample Date:3/23/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detection (F/cc) Fiber Concentration (F/cc) P-1 217 100 16.5 21.02 0.010 0.038 P-2 392 100 CBR CBR 0.005 CBR P-3 60 100 6 7.64 0.035 0.049 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All fiber concentrations were BDL after application of OSHA 's Assigned Protection Factor (APF = 10) for a half-face air perifying respirator (APR). BDL = Below Detection Limit ND = None Detected Sample Prefix:026-33111- Page: Sample Location Andre Williams - Jackhammer CMU- TWA Andre Williams - Jackhammer CMU - TWACarlos - Jackhammer CMU - 30min. Sampled By:Greg St.Louis Date Analyzed:3/31/2011 Analysis Type:PCM NIOSH 7400 Sample Date:3/31/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detectio n (F/cc) Fiber Concentration (F/cc) P-1 443 100 16.5 21.02 0.005 0.018 P-2 63 100 6 7.64 0.034 0.047 P-3 357 100 CBR CBR 0.006 CBR #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All fiber concentrations were BDL after application of OSHA 's Assigned Protection Factor (APF = 10) for a half-face air perifying respirator (APR). BDL = Below Detection Limit ND = None Detected Sample Prefix:026-4511- Page: Sample Location Jorge Hernandez - Jackhammer CMU Jorge Hernandez - Jackhammer CMU - Jorge Hernandex - Jackhammer CMU Sampled By:Greg St.Louis Date Analyzed:4/5/2011 Analysis Type:PCM NIOSH 7400 Sample Date:4/5/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 1 of 1 Sample Number Total Sample Volume Fields Analyzed Fiber Count Fiber Density (F/mm2) Limit Of Detectio n (F/cc) Fiber Concentration (F/cc) P-1 264 100 11.5 14.65 0.008 0.022 P-2 63 100 3 3.82 0.034 BDL P-3 325 100 7 8.92 0.007 0.011 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! Comments: All fiber concentrations were BDL after application of OSHA 's Assigned Protection Factor (APF = 10) for a half-face air perifying respirator (APR). BDL = Below Detection Limit ND = None Detected Sample Prefix:026-41211- Page: Sample Location James Miller, Chisel Block CMU James Miller, Chisel Block MCU - James Miller, Chisel Block CMU Sampled By:Greg St.Louis & Alex Green Date Analyzed:4/12/2011 Analysis Type:PCM NIOSH 7400 Sample Date:4/12/2011 LAB RESULTSS & R Environmental Consulting 5801 Logan Street, Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 AIHA Laboratory ID: 190843 info@srenvironmentalconsulting.com Project Number:011026 Project Address:7340 W 44th Ave Weatridge, CO 80033 Appendix D Certifications OSHA 600482550 U.S. Department of Labor Occupational Safety and Health Administration ALEXANDER GREEN has successfully completed a 3D-hour Occupational Safety and Health Tr~jning Course in Construction Safety & Health Rick C. Knight .sj,22/2ID09 (Trainer) c lll calli u O .-.. "U QI"CI SQI era:: (Date) This recognizes that Alex Green has completed .the requirements for CPRIAED-Adult conducted by Mile High Chapter Date Completed 4/9/11)10 The American Red Cross recognizes this certificate as valid for 1 year(s) from completion date. OSHA 600481969 U,S. Department of la~of . t.;,;·.~; ; -. i ..:_" t:: ~ ;\ Occupational Safety aha I'leafth Administration ALEXANDER GREEN has successfully completed a 30-hour Occupational Safety and He.a1th Training Cou!f:e j~~ ~ . ",' . . Construction Safety & Health Rick C. Knight 5/22/2009 (TraIner) "~ ( : ell! ~ Bo " .-.. ~ t U " E'a ., <1:&1 8 ~ .., ., ii ~ ~ (Date) This recognizes that' ALEX GREEN bas completed the requirements for STANDARD FIRST AID conducted by MILE HIGH CHAPTER Date completed 5/15/2009 The American Red Cross recognizes this certifieat( as valid for 3 year(s) from completion date. Compliance SolutionsOccupational Traiuers, Inc. Certificate of Completion Student Name; Alex Green Company: S&R Envirpnmental Consulting 1 CertifY that the above named student has completed the 40 HoW: HAZWOPER 29 CFR'1910,120(o) Date of Issue: 9/2612.; ~/ ~L~ -Samuel Walters Instructor ---------- STATE OF COLORADO J ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Control Division This certifies that Alexander D. Green Certification No: 15745 has met the requirements of25-7-507, C.R.S. and Air Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Air Monitoring Specialist* 12/10/2010 Expires on: 12110/2011 * This certificate is valid only with the possession of a current DiYision~appJ'oved training course certificatioll in the discipline specified above. STATE OF COLORADO . ASBESTOS CERTIFICATION* Colorado Department of Public Health and~nyh:011ll1ent Air PollutionQ:mtrol Divisjon This certifies that AlexanderD.··Green Certification No: 15745 has met the requirements of 25" 7 ~507, C.R.S. and Air Q~ality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Building Inspector*· Issued: 91312010 Expires on: 91312011 * This certificate is valid Dilly with the possession o/a current Divisioll-approved training course certificatioll ill the disciplille specified ahove. STATE OF COLORADO J ·ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Control Division This certifies that Alexander D. Green Certification No: 15745 has met the requirements of25-7c507, C.R.S. and Air Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Project Designer* Issued: 12/10/2010 Expires on: 12110/2011 * This certificate is valid only with tlte possession of a current Division-approved traitting course certification in the discipline specified above. ACCLAIM ENVIRONMENTAL ISE>R<V 1,0 EiS' 'I NO\ 14367 Lakeview Lane, Broomfield, Colorado 80023 Tel: 303.424.4647 Fax: 303.432.8669 CERTIFIES THAT ALEXANDER GREEN Has successfully completed the AIR MONITORING SPECIALIST -REFRESHER COURSE This course is approved by the Colorado Department of Public Health and Environment in accordance with the AQCC requirements of Colorado Regulation NO.8. Course Date: Exam Date: Certificate No.: Expiration Date: 08/13/10 N/A AE 1 0-087 -AMS-02 08/13/11 kL..--, 5801 Logan Street Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 info@srenvironmentalconsulting.com www.srenvironrnentalconsulting.com Certifies that Alex Green has successfully completed The EPA-Approved AHERA 4 Hour Refresher Course for Building Inspector Refresher .. This Course is EPA Approved under Section 206 of the Toxic Substance Control Act (TSCA) and meets the requirements of Colorado Regulation No.8 Course Date: Exam Date: 5/18/2010 N/A Certificate Number: TR009Bffi Expiratiou Date: 5/18/2011 --.. ~\.. ',. ~ -;.-. \.'.","$]'-l').'::i~ 5801 Logan Street Suite 200 Denver, CO 80216 Phone: 303-297-1645 Fax: 303-297-1646 info@srenvironmentalconsulting.com www.srenvironmentaiconsulting.com Certifies that Alex Green has successfully completed The EPA-Approved AHERA 8 Hour Refresher Course for Project Designer Refresher This Course is EPA Approved under Section 206 of the Toxic Substance Control Act (TSCA) and meets the requirements of Colorado Regulation No.8 Course Date(s): 91112010 -91112010 Exam Date: N/A Certificate Number: TR042PDR-01 Expiration Date: 91112011 Richard Block, President 03/03/2011 LAST NAME GREEN FIRST NAME ALEX FIT TEST REPORT 10 NUMBER 9173 LAST NAME GREEN CU TOM1 FIRST NAME ALEX CUSTOM2 COMPANY SANDR CUSTOM3 LOCATION IDENVER CUSTOM4 NOTE TEST DATE 03/03/2011 PORTACOUNT SIN 80246025 TEST TIME 10:24 N95-COMPANION N DUE DATE 03/03/2012 RESPIRATOR 3M 6000 HALF FACE [100] PROTOCOL OSHA 29CFR1910.134 MANUFACTURER 3M PASS LEVEL 100 MODEL 6000 MASK STYLE HALF FACE APPROVAL NIOSH MASK SIZE MED EFFICIENCY 00:;99% N EXERCISE DURATION (sec} FIT FACTOR PASS NORMAL BREATHING 60 265 Y DEEP BREATHING 60 227 Y HEAD SIDE TO SIDE 60 250 Y "---./ HEAD UP AND DOWN 60 301 Y TALKING 60 305 Y GRIMACE 15 Excl. BENDING OVER 60 392 Y NORMAL BREATHING 60 365 Y OVERALL FIT FACTOR 290 y FITTEST OPERATOR ~. U~WIN ~ ____ ----~~ NAME .. __ DATE 5-]-/( /"'ALE GREEN ( 0311012011 LAST NAME FfRSTNAME FlTTESTREPORi IDNUMSER 9173 lASt NAME ALEX CUStOM1 FIRst NAME GRIOt::N CUSrOM2 COMPANY SANDR CUSrOM3 LOCATION Ot::NVt::R CUSrOM4 NOTE TeSrOATE 0311012011 PORTACOUNT SIN ten tiME 15:11 N9S·COMPANION DUE DATE 03110/2012 m,SPlRATOR 3M 6800 FULL FACE [500) PROTOCOL MANUI'ACrURER 3M MODl:L 6800 MASK STYLE FULL FACE MASK SIZE LARGE EXERCISE DURATION laacl NORMAL BREATHING 60 DEEP BREATHING 60 HEAD SIDE TO SIDE 60 HEAD UP AND DOWN 60 TALKING 60 GRIMACE 15 BENDING OVER 60 NORMAL BREATHING 60 OVERALL FIT FACTOR FITTEST OPERATOR Ur [.J ; IV UNWIN NAME , GREEN ALEX PASS LEVEL APPROVAL EFFICIENCY <99% FIT FACTOR 102000 87000 95700 73300 66500 Excl. 19600 175000 59700 AL~X GREEN 80246025 N OSHA 29CFR1910.134 500 NIOSH N PASS Y Y Y Y Y Y Y y DATE #-/0 ,J" /' DATE 3-/0-/ ( Concentra Medical Centers 420 East 58th Ave Ste 111 Denver,CO 80216 Phone: (303) 292-2273 Fax: (303) 296-4138 EMPLOYER AUTHORIZATION AND INFORMATION FOR RESPIRATORY EVALUATION IEMPLOYER TO COMPLETE THE FOLLOWING: I Employee Name: Green, Alexander D. Employer: S&R Environmental Consulting f:heck Type of Respirator(s) To Be Used I iCheck v" ALL that apply) D Air-purifying (non-powered) D Air-purifying (powered) o Atmosphere supplying Respirator o Combination air-line and SCBA o Continous-Flow Respirator o Supplied-Air Respirator D Open Circuit SCBA D Closed Circuit SCBA D Dust Mask 0112 Face with Canisters 0 Full Face with Canisters Make: Model: Cartridge: ___ _ pecial ,ork Conditions Check ALL That Apply When Wearing Respirator) D High Places D Enclosed Places o Temperature Extremes o Mostly Cold o Protective Clothing D Mostly Hot D Other: ___ --,;=,-_____ -;=,--__ --,=;-__ _ D HAND CARRIED D MAILED D OTHER Questionare will be: Address: 1550 Platte St #381 ~D~E~NV~E~R~ _______ ~C~0 ___ ~80202 Employee SSN: XXX-XX-9173 ~xtent of Useage I 'Check v" ALL that apply) o On a daily basis __ Total Hours D Occasionally -but not more than twice a week __ Total Hours D Rarely -or for Emergency situations only Total Hours ~xpected Physical Effort Required I KCheck v' ALL that apply) I D Light D Moderate D Heavy !Exposure to Hazardous Materials I <CKC"'h-e-c~k-v""'A~L~L~tC-ha"Ct-a-P-P~IY~)'I D Arsenic D Benzene D Coke Oven D Cotton Seed 1 Dust D Cadmium D Formaldehyde D Methylene Chloride D Lead D Textiles D Chromium Other(s): _________________ _ EVALUATION AUTHORIZATION BY: _________ _ Signature of Employer Representative DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE PLHCP 1 WRITTEN STATEMENT for RESPIRATORS (EMPLOYER) I'-P'"HyCCS"'I~C'"'IA""N"'W'"'lo-L'-L""C"'O~M"'po-L:=ET"'E~T"'Hc;EocF~O"'L-cL""O"'W"'IN~G"'I This report may contain confidential medical information and is intended for the designated employer contact only. The Americans with Disabilities Act (ADA) imposes very strict limitations on the use of information obtained during physical examination of qualified individuals with disabilities. All information must be collected and maintained on seperate forms, in seperate files, and must be treated as a confidential medical record, with the following exceptions: • Supervisors and managers may be infonned about necessary restrictions on the work or duties of an employee and necessary accommodations . • First aid and safety personnel may be informed, when appropriate, if the disability might require emergency treatment. Based upon my findings, I have determined that this individual [Check '7 ALL that apply) I q Employee must schedule a medical examination with Concentra Medical Centers ~ Class I -No Restrictions on Respirator Use prior to respirator approval and usage. D Class II -Some Specific Use Restrictions D To be used for Emergency Response or Escape Only D Other: ________ _ o Class 111 -Respirator Use is NOT PERMITIED D Further Testing I Evaluation is Required. 2 o Fit Test Required D Fit Test Performed Satisfactorily o Fit Test Performed Unsatisfactorily D Fit Test NOT Performed at: Concentra Medical Centers o Special prescdpticn eyewesr needed to accommoda!e respirator D Special prescription eyewear needed to accommodate respirator D Facial hair needs to be shaved to assure tight seal on certain face masks. 1 Physician or other Licensed Heallhcare Professional ~mployee must seek further medical evaluation by a private physician who must submit a report to Cnncentrn Medical Centers of his/her findings to Che k v" ALL that apply) The above individual HAS been examined for respirator fitness in accordance with 29 CFR 1910.134. This limited evaluation is specific to respirator use only. Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134. D The above individual ~ been examined by me for respirator fitness. The employee's medical evaluation consisted of a review of OSHA's Medical Evaluation Questionnaire in Appendix C Part A Section 2. In accordance with 29 CFR 1910.134, this limited evaluation is specific to respirator use only. Employees would be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134. D In with specific OS A reqv,'rements, I have informed the above named individual of the results of this evaluation and of any medical conditions resulting from t may requ· furt r ex nation or treatment. Where applicable, the above named individual has been informed of the increased risk of lung cancer the b ne t f s ~1d asbestos, lead and/or other chemical exposure{s). ~ \ ¥'t;- ~----~~~~--~---------­Physician's Name (Printed) '6 -\ \) -:?€.H) Physician's License Number (Optional in Most States) Date of Exam Expires On Page 1 of 1 Print Date: 08/10/2010 To be maintained in the employee's file with a copy to the employee Revision Date: 06/29/1999 Patient Information Test Information Name ALEXANDER D GREEN Test DatelTime ID 522479173 Post Time Age 25 Test Mode Height 5 ft 10 in Interpretation Weight 170 Ibs, 8MI 24.6 Predicted Ref Gender MALE Value Select Ethnic CAUCASIAN Tech 10 Smoker NO Automated QC Asthma NO BTPS (IN/EX) Test Results Your FEV1 is 102% Predi cted Pre-Test Parameter FVC [LJ FEVl[LJ FEV1/FVC PEF[Llmi nJ FEF25-75[Lls] FEHs] Tria17 TrialB Pred 4.794:)12) t 5.,49 4.00 3.94;; 4.54 o . 84 0 . 82 0.83 530 543 608 4.204.024.69 Eu,One(TM) DIAGNOSTIC 2.t9 (c) odd 2000-2007 SN 63921 RccNo 1443 08flOllO 08:37 08110110 08:29 DIAGNOSTIC NLHEP NHANES III BEST VALUE Pre-Test 1 Var=0.64L 13.8%; FVC Var=0.67L 12.3%; Sessi n Quality D 6.15 7.13 \ Interpretation ormal, but the values shouldn't be used for comparisons wi prev.or subsequent te Caution: Maneuve s Not Reproducible -Interpret With Care. \ ~ ~ V\~ ~~'Ay:~ '\ "~\ \. 'C' " Legend " .. f'J~~ \ -'. H~a.LL '\ 1"'1·· .. · .. ·; .. ·r ........ · __ --------. Pre-Test Tria17 14 12" ........... Pre-Test Tria18 " o ______ ------L.---'\'Ji\)'\ i /" /V-'-10 .... ..:l <> Predicted '-~ '" 8 " '-6 ..:l ~ " 0 4 r< '" 2 0 I:J:!.:"':.:·:·U···,·····,············V;~····, ; -'\~\ V' /V \ I .... M.... + '\'''''~'V'''''' ... 1// ..... ;......... i .............. , .... ·· .. ·; 1 "'rh ['\!', " 23456 Volume[L] 10mm/L 7 8 81 T···········, .. ············, T············ T············, , ........... T···········,···········, , ............ , ............ , , ........... , , ..:l 71 .... · .... ······+··········+········· .. ··+ .. ··········+ .. ·· ........... + ............ i ................ ; ........... + .......... -+ ......... , .................. j ................... :.. .......... , .............. j ................. f.. ................ ; '-~ 6IJ;~~~~I.· .•••• · •• 1 ••.•••••••••• r· •.• ·.J J .••• 1 •••••••• ] •••••••.••••••• 1· •.•• \ : ! ........... /:/'> ...... :-.. --........ +-................. ; ......... +......... + ................. , ......... +......... +........ ; ..................... ; .................. ;......... ., ........... ; ................... ;........... ,........ , ~ 3}ffY/+' ··t············ + ............ + : .......... , ........... , ............. + .... + .................. ; .................. ; ................... ; ....... ; ................... ; ................. ;. ; S 2f ... t ............ ··+ , ............. + + ............. + .......... ; ............... + + ............. -+ ; ............. -+ , .............. + 1· ............ ) r< ; g 11-........ ·· .. ·; .... ·········., ............ · .. ·; .. ·· ...... ···.;.· ...... ···· .. ·;·········· ...... ··1 .............. ··; .... ····· .. ····+··········+ .... · ........... ; ................... , ......... + ......... , .............. + ........... + ............ ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Time[s] 10mm/s 12. Yes eNd 13. Y"~ Yes N Yes N 14. YesB 15. No No No Ye No Ye No Ye Ye Ye Ye I TO THE PLHCpl Concentra Medical Centers 420 East 58th Ave Ste 111 Denver, CO 80216 Phone: (303) 292-2273 Fax: (303) 296-4138 OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE Have you ever had an injury to your ears, including a broken ear drum? Do you currently have any of the following hearing problems? a. Difficulty hearing b. Wear a hearing aide c. Any other hearing or ear problems Have you ever had a back injury? Do you currently have any of the following musculoskeletal problems? a. Weakness in any of your arms, hands, legs, or feet b. Back pain c. Difficulty fully moving your arms and legs d. Pain or stiffness when you lean forward or backward at the waist e. Difficulty fully moving your head up or down f. Difficulty fully moving your head side to side g. Difficulty bending at your knees h. Difficulty squatting to the ground i. Climbing a flight of stairs or a ladder carrying more than 25 Ibs. j. Any other muscle or skeletal problem that interferes with using a respirator. Check v the ONE that applies D I have reviewed Part A Section 2 of this questionnaire with the employee and I do not recommend that a physical examination be performed . . Dr I have reviewed Part A Section 2 of this questionnaire with the employee and I am recommending " that a physical examination be performed. D I have reviewed Part A section 2 of this questionnaire without the employee and I do not recommend that a physical <)xamination be performed. D I have reviewed Part A Section 2 of this question without the employee and I am recommending that a \al xamination be performed. PLHC Date TO BE FILED IN EMPLOYEE'S MEDICAL FILE Page 4 of 7 Print Date: 08/10/2010 Revision Date: 10106/2003 Concentra Medical Centers Service Date: 08/10/2010 420 East 58th Ave Sle 111 Denver, CO 80216 Phone: (303) 292-2273 Fax: (303) 296-4138 Physical Exam Name: Green, Alexander D. SSN: XXX-XX-9173 Date: 08/10/2010 Examination Results __ Able to perform essential functions as listed. __ Unable to perform all essential functions as listed. Please list failed essential function(s): No medical restrictions are indicated. __ The following medical restrictions are indicated: Recommend further evaluation. Remarks: Eval -Pre-Placement Page 4 of4 © 1996 -2010 Concen\ra Health Services, Inc. All Rights Reserved. Provider Signature Revision Date: 01/24/2010 STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Conn'ol Division TIllS certifies that Greg St. Louis Certification No: 11407 has met the requirements of 25-7-507, C.R.S. and Air Quality Control ConU1llssion Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Air Monitoring Specialist* Issued: 4/30/2010 Expires on: 4/30/2011 * This certificate is valid 011/Y with the possessiolJ of a current Divisi(Ju-approved tmilling course certificatio11 ill the discipline specified above. ACCLAIM ENVIRONMENTAL Is ER>V ICES I· Nci 14367 Lakeview Lane, Broomfield, Colorado 80023 Tel: 303.424.4647 Fax: 303.432.8669 CERTIFIES THAT GREG ST. LOUIS Has successfully completed the AIR MONITORING SPECIALIST -REFRESHER COURSE This course is approved by the Colorado Department of Public Health and Environment in accordance with the AQCC requirements of Colorado Regulation NO.8. Course Date: Exam Date: Certificate No.: Expiration Date: 02/18/11 N/A AE11-016-AMS-R-01 02/18/12 tA- STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Control Division This certifies that Greg St. Louis Certification No~ 11407 has met the requirements of25-7-507, C.R.S. and Air Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Air Monitoring SpeciaIist* 4/30/2011 Expires on: 4/30/2012 * This certificate is valid Dilly witll the possession of a current Dh·jsioll-approved trailling course certification ill the discipline specified above. 03/10/2011 ( IDNUMBER LAST NAME FIRST NAME COMPANY LOCATION NOTE TEST DATE TEST TIME DUE DATE RESPIRATOR MANUFACTURER MODEL MASK STYLE MASI(SIZE EXERCISE NORMAL BREATHING DEEP BREATHING HEAD SIDE TO SIDE HEAD UP AND DOWN TALKING GRIMACE BENDING OVER NORMAL BREATHING OVERALL FIT FACTOR FITTEST OPERATOR NAME LAST NAME FIRST NAME FIT TEST REPORT 3806 ST.LOUIS CUSTOM1 GREG CUSTOM2 SANDR CUSTOMS DENVER CUSTOM4 0311012011 PORTACOUNT SIN 14:05 N95·COMPANION 03110/2012 3M 6800 FULL FACE [500) PROTOCOL 3M PASS LEVEL 6800 FULL FACE APPROVAL MED EI'"I'ICIENCY <99% DURATION (secl FIT FACTOR 60 138000 60 162000 60 13100 60 45300 60 26600 15 Excl. 60 mMO 60 111000 22900 ~.~ S.MASSEY f / .~~~ .~ GRE~ .. LOUI ST.LOUIS GREG 80246025 N OSHA 29CFR1910.134 500 NIOSH N PASS Y Y Y Y Y Y Y y DATE? -(d· ;)gIl DATE ]-;tJ~// 03/03/2011 LAST NAME ST. LOUIS FIRST NAME GREG FIT TEST REPORT ( ID NUMBER 3806 LAST NAME ST. LOUIS CUSTOM1 FIRST NAME GREG CUSTOM2 COMPANY SANDR CUSTOM3 LOCATION DENVER CUSTOM4 NOTE TEST DATE 03/03/2011 PORTACOUNT SIN 80246025 TEST TIME 10:00 N95·COMPANION N DUE DATE 03/03/2012 RESPIRATOR 3M 6000 HALF FACE [100J PROTOCOL OSHA 29CFR1910.134 MANUFACTURER 3M PASS LEVEL 100 MODEL 6000 MASK STYLE HALF FACE APPROVAL NIOSH MASK SIZE LRG EFFICIENCY <99% N I;XERCISE DURATION (sec) FIT FACTOR PASS NORMAL BREATHING 60 3250 Y DEEP BREATHING 60 5310 Y HEAD SIDE TO SIDE 60 3320 Y ( HEAD UP AND DOWN 60 3610 Y TALKING 60 7300 Y GRIMACE 15 Excl. BENDING OVER 60 4400 Y NORMAL BREATHING 60 16900 Y OVERALL FIT FACTOR 4670 y FITTEST OPERATOR /H~ DATE)-"5 -.M/I UNWIN / NAME . ~~. cd Cere:. G"R(o" /" . LOU(t' DATE 3-3-// <;Concentra Medical CQntQrs 420 East 58th Ave Ste 111 Denver,CO 80216 Phone:(303)292-2273 Fax:(303)296-4138 PLHCP1 WRITIEN STATEMENT for RESPIRATORS (EMPLOYEE) "se"rvice Date:~O::::3/c..:1-=O.:.:/2~O:....!1...!1 _ Employee Name: ST Louis.Gregory P. IEmployee SSN:XXX-XX-3806 Address: 25044 E 5th Ave AURORA CC 80018 Employer:S&R Environmental Consulting You were evaluated in this office of your medical status related to your physical capability to wear a respirator.(Check v one that applies) fiThere were no abnormal findings that would hamper your ability to perform your job duties while wearing a respirator.D The abnormal findings listed below were not related to wearing a respirator but should be reported to your personal physician for further evaluation. Based upon the results of this evaluation it is my opinion that you:(Checkv'ALL that apply) ~HE qualified to wear a respirator. Have the fol/owing restrictions concerning respirator usage: DARE NOT qualified to wear a respirator. ~Require further testing by your private physician who must submit a written report of his/her findings to <:>Concentra Medical Centers so that a final decision on your ability to wear a respirator can be made.oMust wear Special prescription eye-wear needed to accommodate respirator. DMust use an Eye glass conversion kit. DMay need to shave Facial hair to assure tight seal on certain face masks. DNeed to stop smoking. ALL that apply The above individual.I:!AS.been examined for respirator fitness in accordance with 29 CFR 1910.134.This limited evaluation is specific to respirator ~se only.Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. is evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134. ve individual ~been examined by me for respirator fitness.The employee's medical evaluation consisted of a review of OSHA's Medical Evaluation Questionnaire in Appendix C Part A Section 2.In accordance with 29 CFR 1910.134,this limited evaluation is specific to respirator use only.Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician.This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134. O'fnaccordance with specific OSHA requirements,I have informed the above named individual of the results of this evaluation and of any medical conditions resulting from exposures that may requir na tment.Where applicable.the above named individual has been informed of the increased risk of lung cancer attributable to ombined effect of smokjng and asbe os,lead and/or other chemical exposure(s). plrators must be properly selected based on the contai ent and concentrat/oll.!flvelS to which the worker will be exposed.Failure to follow the use and fitting instruction and warnings for proper use contained on the resp/fa 9and/or failure to wear the respirator during al/times of exposure can reduce the respirator's effectiveness and result in sickness or death.Weare e train In the proper care of any respirator.Refer to product literature and packaging for specific information regarding fit, use and/or limitations. p !OO;t:ev~n Jjrtlhlll;)Jl,M.D. ':)LHCP Narri~2l(~H::ttMti'}Pr:)----Expiration Date ~PhySIClan or other Licensed Healthcere Profeaoional To be maintained in the employee's file with a copy to the employee rplhcp_stmuesp_employee Page 1 of 1 Print Date: Revision Date: 03/10/2011 04/06/2000 Concentra Medical Centers 420 East58th Ave Sle 111 Denver,CO 80216 Phone:(303)292-2273 Fax:(303)296-4138 ,--,••NlPLOYER TO COMPLETE THE FOLLOWING:I EMPLOYER AUTHORIZATION AND INFORMATION FOR RESPIRATORY EVALUATION Employee Name:ST Louis,Gregory P. Employer:S&R Environmental Consulting ~heck Type of Respirator(s)To Be Used IkCheck v'ALL that apply)IoAir-purifying (non-powered)0Air-purifying (powered)oAtmosphere supplying Respirator D Combination air-line and SCBA D Continous-Flow RespiratoroSupplied-Air Respirator D Open Circuit SCBA 0Closed Circuit SCBAoDustMask01/2 Face with Canisters 0 Full Face with Canisters Make:Model:Cartridge:_ ipecial Work Conditions Check v'ALL That Apply When Wearing Respirator) D High Places 0 Enclosed Places 0 Protective ClothingoTemperatureExtremes0MostlyCold.0Mostly Hot DOther:---------==-----------~~--------~~-------Questionare will be:0 HAND CARRIED 0 MAILED 0 OTHER DO NOT WRITE BELOW THIS LINE Address: 25044 E 5th Ave AURORA CO 80018 Employee SSN:XXX-XX-3806 !Extent of Useage IkCheck ../ALL that apply)IoOnadailybasis__Total HoursoOccasionally-but not more than twice a week __Total HoursoRarely-or for Emergency situations only __Total Hours !Expected Physical Effort Required I kCheck ..../ALL that apply)IoLight0Moderate0Heavy @xposuretoHazardousMaterials I r.:kC::-:h-e-c:-k-v'-=-A-::-:L:-:L-t:7h-a:-ta-p-p""""'"ly-:)'1 D Arsenic 0 Benzene D Coke Oven 0 Cotton Seed /DustoCadmium0FormaldehydeoMethyleneChloride0Lead D Textiles 0 Chromium Other(s):_ DO NOT WRITE BELOW THIS LINE EVALUATION AUTHORIZATION BY:_ SignatureofEmployerRepresentative DO NOT WRITE BELOW THIS LINE PLHCP 1 WRITTEN STATEMENT for RESPIRATORS (EMPLOYER)""P-HY""'S=I-C::C"'""'IA'"'"N""-'W-=-=IL-:-L--=C:-::O::-:M-::-:P::-:-L-=E==T=E-=T::-:H=E-=F:-::O-'-L:-LO=W:-:=IN-:-:G~I "hls report may contain confidential medical information and is intendedfor the designated employercontactonly.The Americanswith DisabilitiesAct IDA}imposesvery strict limitationson the useof information obtained duringphysical examinationof qualified individualswith disabilities.All information ~ust becollected and maintained on seperate forms,inseperatefiles,and must betreated as a confidential medical record.with the following exceptions: •Supervisors and managers may be informedabout necessaryrestrictions on thework orduties of an employee andnecessary acccrnmodatlons. •Firstaid and safety personnelmay be informed.when appropriate,if thedisability mightrequireemergencytreatment. B~upon my findings,I have determined that this individual kCheck '7ALL that apply)I§EP10yeemustschedule a medicalexamination with Concentra Medical Centers prior to respiratorapproval and usage. Class I -No Restrictions on RespiratorUse Class 11 .-Some Specific Use Restrictions 0 To be usedfor Emergency Responseor Escape Only 0 Other:_ D Class 111-Respirator Use is NOTPERMI1TEDoFurtherTesting/Evaluationis Required.2 D FitTest Required 0FitTest PerformedSatisfactorilyoFitTestPerformedUnsatisfactorily0FitTestNOTPerformedat:Concentra Medical CentersoSpeCialprescriptioneyewearneededtoaccommodaterespirator0Specialprescriptioneyewearneeded to accommodaterespirator D Facial hair needs to be shavedto assure tight seal on certain face masks. 1Physician or other Licensed Healthcare Professional ~mployee must seekfurther medicalevaluation by a private physicianwho must submit a reportto Concentra Medical Centers of his/herfindings to C,hpck ../ALL that apply) The above individual.l:!M beenexaminedfor respiratorfitness in accordancewith 29 CFR 1910.134.This limitedevaluation is specific to respirator use only.Employeesshould beinstructed to report any difficulties in usingrespirators or changeof any physical statusto their supervisoror physician. This evaluation includedthe RespiratoryQuestionnaireoutlined in 29 CFR 1910.134.o The above individual~been examined by mefor respiratorfitness.The employee'Smedicalevaluation consisted of a reviewof OSHA·sMedical Evaluation QuestionnaireinAppendix C Part A Section 2.In accordance with 29 CFR 1910.134,this limitedevaluation is specific to respirator use only.Employeeswould beinstructed to report any difficulties in using respiratorsor changeof any physicalstatusto their supervisor or physician.This evaluation included the RespiratoryQuestionnaire .,(oUtlined In2~101013~l'-l In accordan·~th specifiC~I.irem'ill'lt.s"+have·informed the above named individual of the resultsof this evaluationand ofany medicalconditions resultingfrom exposures that may requirefurtherex nation or treatment.Whereapplicable.the above namedindividual has been informed of the increasedrisKof lung cancer attributap~the combined eft smoking and asbestos,lead and/orother chemicalexposure{s). "-./P~cian'g Signature Physician'S License Number (Optional in Most States) r_plhcp_stmuesp _employer Page 1 of 1 To be maintained in the employQQ's fHo with a copy to the employee Print Date; Revision Date: 03/10/2011 Oo/Z~I1~~~ .'u~1fu~tZV1U .,',...LAST NAME ST LOUiS F!T TEST REPORT FIRST NAME GRt;G <.; to NUiiI"i8ER 3806 LAST NAME ST LOUIS FiRST NAME GREG COMP1NY LOCATiON "tE TEST DATE TEST TIME DUE DATE RESPiRATOR MANUFACTURER MODEL MASK STYLE MASK SIZE EXERCISE NORMAL BREATHING DEEP BREATHING HEAD SIDE TO SIDE HEAD UP AND DOWN ~TALKING GRfMACE BENDING OVER NORMAL BREATH!NG OVERALL FIT FACTOR F:rrEST OPERATOR NArv'E (~ SScRENVIRONMENTAL DENVER 04/02/2010 16:20 04/02/2011 3M 600Q HALF FACE I100J 3M 6000 HALF FACE LARGE DURATiON isse, 60 60 60 60 60 15 60 60 CUSTOM1 CUSTOiit'i2 CUSTOM3 CUSTOflti4 PORTACOUNT SIN N95-COMPANION PROTOCOL PASS LEVEl APPROVAL EFFICIENCY <99% 80246025 N OSHA 29CFR1910.134 100 NIOSH N FiT FACTOR PASS. 67100 Y 88200 Y 484000 Y 112000 v, 12600 Y Excl. 14200 v, 627(X)v, 34400 H~REN8l::R~~'.'4TIOISt-- / y DATE 1""lAT-1..11-'>It: '--./ cr/vJo 7/'V/o "---.,.. Pati9D.t Name ID Ag~ Height Weight Gender Ethnic smoker Asthma Information GREGORY P St LOOIS 523633806 37 6 ft 1 in 280 Ibs,BMI 36.7 MALE CAOCASIA,N NO NO Te~tInfo~tion Test Date/Time post TimeTestModeInterpretation Predicted Ref Value Select Tech ID Automated QC BTPS (IN/EX) Test Results Your FEVl is 86%Predicted Pre-Test Parameter Best Tria14 TrialS Trial 3 Pred %Pred FVC [L]5.01 5.01 4.82*4.76*5.91 -as FEVl [L]4.07 4.07 3.89 3.84*4.71 86 FEV1/FVC 0.81 0.81 0.81 0.8.1 0.80 101PEF[L/min]631 631 606 619 658 96 FEF25-75 [L/s]3.68 3.68 3.65 3.72 4.43 83FET[s]6.16 6.16 6.11 6.37 -.-- *indicates Below LLN or Significant Post Change EasyOne(l'M)DIAGNOSTIC 1.19 (e)ndd 2O(lO-200'7 SN 639%1 RccNo 1817 03/10/11 ).5:33 03/10/11 15:31 DIAGNOSTIC NLHEP NHANES III BEST VALUE ON-.--I 1.02 Pre-Test Interpre.-4n'~? FEV1 Var=0.17L 4.2%;NO~Z:t~FVC Var=0.19L 3.8%;Session Quality C ........,~'-'T'--"',T--T:-'i:i::E:I:I::I~:,E'~=l "-----' 1 2 1 2 3 4 5 6 7 8Volume[L]10mm/L H<,gtn ...:I•....• Q}e.-l I 0'------'>- ....~.--,, ••••••••••,1"••-••••••••••,,,+_.... t··················j················i················t··················i··················i··················t····,·····",··,,·I···················!················t····· Legend --Pre-Test Tria14 --_.Pre-Test TrialS...........Pre-Test Tria13 ~Predicted .......!···············..1·"··..·,"',·..··[·,,···············1 3 6 7 8 9 10Time[s]10mm/s 1545111314 , ! 12 16 're, Concentra Medical Centers 420 East 58th Ave Ste 111 Denver.CO 80216 Phone:(303)292-2273 Fax:(303)296-4138 Phyaiolan Respiratory Ex~mination R@cord ',,------,~----------------------------------------------------------------------------~--Service Date: 03/10/2011 G@nd@r~Male Patient Name: ST Louis,Gre~ory p Day Time Phone:()-x Address: 25044 E 5th Ave Night Time Phone:(303)548-1093 AURORA.CO 80018 Race:(Circle One)Asian /Black /Hispanic Indian /White /Other SSN:XXX-XX-3806 Employer:S&R Environmental Consulting I EXAMINATION I 1'b\" I TESTING I Testing necessary for 29 CFR 1910,134 does not include testing necessary for other OSHA medical surveillance:Height Weight Pulse Temperature Blood Pressure Respiration Heart Lungs ~;ars Ear Drums Nose Buccal Cavity Pharynx Musculoskeletal Hernia EKG Performed •Comments,_ YES NO AS AB AS AB AS 'AS AB AB YES Spirometry Performed •Spirometry Results Attached •Comments:-------------------------- YES NO YES NO This Examination Expires on:-~~~+I-~'~I==~!~-- ~-,At:am/pm Chest x-ray Performed •Results: •#of views •X-Ray # •Comments:_ B-reader Required •Date sent: •Results: Vision Testing •Right Eye •Left Eye •Color •Depth Perception •Peripheral Audiometric Test Ordered •Results:Within Range •Comments ..'_ WNL YES NO YES NO YES NO Concentra Medical Centers &to NO Near Near ~ ~ ~ YES NO Out of Range Blood Tests Ordered •Tests Ordered:....:__-:-:-~:--:::---___:=--~:_=_--•Results:Within Range Out of Range •Comments:----------===----- YES NO Physician's Name (print) Urlnalysls Ordered •Results: •Comments:~------------------------- ~'>'".ES NO In Ran ut of Range ~ To be maintained in employee's medical record Page 1 of 1 Print Date: Revision Date: 03/10/2011 OS/2811888r_resp _exam_record I(EMPLOYER AUTHORIZATION AND INFORMATION FOR RESPIRATORY EVALUATION IEMPLOYER TO COMPLETE THE FOLLOWING:I Concentra Medical Centers 420 East58th Ave Ste 111 Denver,CO 80216 Phone;(303)292-2273 Fax:(303)296-4138 ,-' Employee Name:5T Louis,Gregory P. Address; 25044 E 5th Ave ~ AURORA CO 80018- Employee SSN:XXX-XX-3806Employer:S&R Environmental Consulting Fheck Type of Respirator(s)To Be Used IkCheck ../ALL that apply},oAir-purifying (non-powered)0Air-purifying (powered)o Atmosphere supplying RespiratoroCombinationair-line and SCBAoContlnous-Flow RespiratoroSupplied-Air RespiratoroOpenCircuitSCBA'0Closed Circuit SCBADDustMas'k 01/2 Face with Canisters 0 Full Face with Canisters Make:Model:Cartridge:_ ipecial Work Conditions· Check.,;'ALL That Apply When Wearing Respirator)oHigh Places 0 Enclosed Places 0 Protective ClothingoTemperatureExtremes0MostlyCold0MostlyHotoOther:-=::---;;;;=---==-_oHAND CARRIED'0 MAILED 0 OTHER ~xtent of Useage 'kCheck../ALL that apply)o On a daily basis __Total HoursoOccasionally-but not more than twice a week __Total HoursoRarely-or for Emergency situations only __Total Hours ~xpected Physical Effort Required 'kCheck vALL that apply),o Light 0Moderate 0 Heavy . ~xposure to Hazardous Materials 'kr.:CO:-h-e-c'-k-.,;'-=-A"'-'L:-:L-tC:-h-a-ta-p-pC:-ly""')',o Arsenic 0 BenzeneoCokeOven.D Cotton Seed /DustoCadmiumDFormaldehydeDMethyleneChloride0LeadoTextiles0Chromium Other(s):_ EVALUATION AUTHORIZATION BY:_Questionare will be: DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE SignatureofEmployerRepresentative DO NOT WRITE BELOW THIS LINE plHCP 1WRITTEN STATEMENT for RESPIRATORS (EMPLOYER)--""'S""'IC""'IC:-A":-:NC:-W::-:I:-:-L"-L-=C:-::O:-::M':":P=-=L-=E=T==E:-::T=CH""'E::-F=-O""'L:-::L-:O::-:'W':'::7IN=>C;, l\......-/reportmay contain confidential medical informationand is intendedfor the designated employer contact only.The Americans with Disabilities Act (ADA)imposesvery strict limitations onthe useof informationobtained during physical examination of qualified individuals with disabilities.All information must becollected and maintained on seperateforms,in seperate files,and must be treated as a confidential medical record,with the following exceptions: •Supervisorsand managers may be informed about necessary restrictionson the work or duties ofan employeeand necessary accommodations. •Firstaid andsafety personnel may be informed,when appropriate,ifthe disability might require emergency treatment. Based upon my findings,I have determined that this individual kCheck'7ALL that apply)ID~oyee mustschedule a medical examination with Concentra Medica!Centers priorto respirator approval and usage. Wcla~s I -No Restrictions on Respirator UseDClassII-Some Specific Use Restrictions D To be usedfor Emergency Response or Escape Only 0 Other:_oClassIII -Respirator Use is NOT PERMllTEDoFurtherTestingIEvaluationisRequired.2oFitTes!Required D Fit Test PerformedSatisfactorilyoFitTestPerformedUnsatisfactorily0FitTestNOTPerformedat:Concentra'Medical CentersDSpecialprescriptioneyewearneededtoaccommodaterespirator0Specialprescriptioneyewearneededto accommodate respiratoroFacialhairneedstobeshavedtoassuretightsealoncertainfacemasks. 1Physician or other licensed Healthcare Professional i:mPIOyee must seek further medicalevaluation bya private physicianwho must submit a report to CQncentra Medica!Centers of his/herfindings to ~ Ch~k -/ALL that apply) 7Theabove individual H8S.been examined for respiratorfitness in accordance with 29 CFR 1910.134.This limitedevaluation is specific to respirator useonly.Employees should be instructed toreportany difficulties in usingrespirators or Changeof any physical status to their supervisor or physician. Thisevaluation included the Respiratory Questionnaireoutlined in 29 CFR 1910.134.o The above individual HAS NOT beenexaminedby me for respiratorfitness.The employee's medical evaluation consisted of a review of OSHA's Medical Evalualion QUe~nn~if1:;inAppendi"C P",,!A Se••!!on2.InllccordllnCQwith 29 CFR 1910.134,this limited evaluation is specific to respirator use only.Employees would be instructed to'port any difficulties in u&ingrsspirators or change ofany physical status to their supervisor or physician.This evaluation included the Respiratory Questionnaire uUinedin 29 CFR 1910.134. Inaooordaneewith epocrnc OSHA r••quirements.Ihave informed the above named individual ofthe results ofthis evaluation and of any medical conditions resulting (rom '>xpoo ro at m require further explanation r treatment.Where applicable,the above named individual has been informed of the increased risk of lungcancer Ieto-1R co smokin and asbeslo ea and/orother chemical exposure(s).ltitt'K .t,.NELSON ·D.O.<c:> Physlci n's slgnatpre h PhYSiCiZ'S~(Printed):1910 W.C)~o·1& Physician's License NJmber (Optional in Most States)Date of Exa ovlo~p, Expires On rylhcp_stmLresp_employer Page 1 of 1 To be maintained in the emolevee's file with a CODV to the emolovee Print Date: Revision Date:. 04/02/2010 06/29/1999 (Concentt»Medical Centers 420 Easl 58th Ave sie 111 Denver,CO 80218 pnon;;(303)292.2273 F<n (303)290·413B PLHCP1 WRITTEN STATEMENT for RESPIRATORS (EMPLOYEE)"-- Service Date:04/02/2010 Employee .Name: ST Louis,Gregory P. Employee SSN:XXX-XX-380o Address: .25044 E 5th Ave AURORA CC 80018 Employer:S&R Environmental Consulting You were evaluated in this office of your medical status related to your physical capability to wrr a respirator.(Check v one that applies) EfThere were no abnormal findings that would hamper your ability to perform your job duties while wearing a respirator.oThe abnormal findings listed below were not related to wearing a respirator but should be reported to your personal physician for further evaluation. Ba¢d~upon the results of this evaluation it is my opinion that you:(Check V .Ab,.Lthat apply) ~.RE qualified to wear a respirator,o Have the following restrictions concerning respirator usage: 'lI\RE NOT qualified to wear a respirator. '-........-~equirefurther testing by your private physician who must submit a written report of his/her findings to <:: Concentra Medical Centers so that a final decision on your ability to wear a respirator can be made.o Must wear Special prescription eye-wear needed to accommodate respirator.o Must use an Eye glass conversion kit.o May need to shave Facial hair to assure tight seal on certain face masks.o Need to stop smoking. ALL that apply] The above individual.l:lAS.been examined for respirator fitness in accordance wilh 29 CFR 1910.134.This limited evaluation is specificto respirator use only.Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134.o The above individual ~been examined by me for respirator fitness.The employee's medical evaluation conetstee of a review of OSHA's Medical Evaluation QUjS'lionnaire in Appendix C Part A Section 2.In accordance with 29 CFR 1910.134,this limited evaluation is specific to respirator use only.Employees should be instructed to/eport any difficulties in using respirators or change of any physical status to their supervisor or physician.This evaluation included the Respiratory Questionnaire utlined in 29 CFR 1910.134. In accordance with specific OSHA requirements.Ihave informed the above named individual of the results of this evaluation and of any medical conditions resulting from exposures that may require further explanation or treatment.Where applicable,the above named individual has been informed of the increased risk of lung cancer attributable to the combined effect of smoking and asbestos,lead and/or other chemical exposure{s). RC3pirators must be propOrly sa/Betad based on the conteinmen:and concontratlon laval"to which the worker will be exposed.Failure to follow tne,us«and fitting instruction and wamlngs for proper USCIcontained on the IEspirator packaging anct/or failure to wear the respirator during all times of Q)(posuro can reauc«tb«respirator's effe"tivenCslI and result in sickness or death.Wearer must be trsined in theproper CB'"of any rospirator.Rorer to product litemtum IJndpackaging for specific information rHf/arding fit,P1Pifz~ m'RK t,mtSON l:i.Q. Employee's Signature tPtfl!!J--!~l! -;Expiration Date ~,,-.4CP N~m9 (printed) 1pnYSICI,mor other Licensed l Ieelthcerc Profoooior.al To be maintained In the employee's file with a oopy to thQ Qmployee r_plncp_!:tmt_resp_employee Page 1of 1 Print Date: Revision Date: 04/02/2010 04/06/2000 ("Concentra Medical Centers 420 East 58th Ave Ste 111 Denver,CO 80216 Phone:(303)292-2273 Fax;(303)296-4138 (Physi.cian Respiratory Examination Record"-...,..~ Service Date: 04/02/2010 Gender:Male Patient Name: ST LoujsGregory P ,.;I Day Time Phone:(303)297-1645 x Night Time Phone:(303)929-7876Address: 25044 E 5th Aye Race:(Circle One)Asian /Black /Hispanic .Indian /White /OtherAI'BORA CO 80018 Employer:S&R Environmental ConsultingSSN:XXX-XX-38Q6 I EXAMINATION I Height Weight Pulse Temperature Blood Pressure Respiration Heart (.1g5'---"cars Ear Drums Nose Buccal Cavity Pharynx Musculoskeletal Hernia ~3~tVl. ITESTING I Testing necessary for 29 CFR 1910.134 does not include testing necessary for other OSHA medical surveillance:.»: YES@'''''\5r''\b ..,·~!1t·.:J1 ~~-t.c:>~& EKG Performed •Comments ----~----------------~~----- WNL ®J NO YES NO =c, YES ~ YES NO "--.../ Spirometry Performed •Spirometry Results Attached. •Comments:---------------------------/~ Chest x-ray Performed •Results: •#of views •X-Ray # •Comments:------------------------- AS AS AB AB AB AB AS AS YES YES@iB-reader Required •Date sent: •Results: ,~..' Vision Testing IF /')(Y~NO •Right Eye (yV/.k;{jI/~Far 'z..oJ'Y;Near .2Cy~ •Left Eye Far 'Who Near ~ •Color -W IV [ •Depth Perception /\./L-- •Peripheral '(,'5{;' ~"1'" Audiometric Test Ordered YES W •Results:Within Range Out of Range •Comments:~, Blood Tests Ordered YES & •Tests Ordered.,_ •Results:Within Range Out of Range •Comments:= I RESPIRATOR FIT TEST I o Not performed at Concentra Medical Centers DPass DFailoReturn to Clinic on 'At:am/pm This Examination Expires on:071/0;;..-aoI ! t/{;d~~J .PhYSICians Signature .I .0 d d /yr~ES~.NOUnnaYSISrere~' I KIRK t.NELSON l'.C.•Results:Within Range Out of Range =<:»'(..)•Comments:~Physician s Name print /"~r.;?-er-r C £,"",5/-t/2 ,~;C~/(9-V/T ~L>'-- To be maintained in employee's medical record .r'.fl)/I"~;-cs:..2.-7u9~~/..; ~resp_examjecord Page 1 of 1 Print Date:.04/0Z/2010 PAvj••jn"n",f••·nF>nU/1UQQ ) ADVANCED TOXICOLOGY NETWORK :3560 Air Center Cove,Suite 101 'emphis,TN 38118 (SM)~~~-7479 CUSTODY AND CONTROL FORM for RAPID DRUG SCREENING AND CONFIRMATION TESTING (DO NOT USE FOR D.O.T.COLLI::CTIONS) '-"A.Employer Name,Address,1.0.No.£3~(Jfi~t~;~g~;:~ 902160757 :.,';,~·r.i;,t,.11i~.t..,.j':);~..~~':'~,.._<!"-' ..--'P .(....._./•....•..•.<.c./{(:?)",,,,....-v.l/c....-"--"'</••••;s.•...---'7:;;;.0;.I.-J't:,,"r -..L. '~;,}::;'..:>''''j;,~~>:.r.::~~:r;~./};.,""[·:?E.\/:r-J.;~~.:.,.•'I B.Donor Information .,.>I,""~'~'7 7.-../."'7,.te,""••.•'»+r t ,»,,'A",./••••••.-;;,.-.~."" -,,.<".'"t 1"'-">1---";,./t»,"",'(,.J ,.SSN ;<1".-.First ,.-:,;,.-,f"C::;;,,Name l//'t:.._.?c:»:.•...-.-~~•..,...•,<'--- ..:--""'"M.I/"'"";' .t"'--•.•.•~..•. Last >0"Name ..//...".._-1'".,J~...•i'.••.•S'~---.~""'-"-'..."" All. ID (oplional).-,'-7 .~:~Donor Phone -\ (Daytime)'.,j Donor Phone (Evening). [.).1 (>,-7~J:~?/' ,.:5 (1.r11-'(:, (opliona'l) Donor Certification: "-----"I certify that the specimen accompanying this form is my own and that I provided it to the collector.Further,I certify that the specimen was sealed with a tamperprool seal in my presence and that the inlormation provided on this form and on the label is correct.I consent to the analysis of the specimen accompanying this form.Also:consent to the release by the collector and/or the laboratory of the results of the analysis as well as the information recorded on this form to the organization and/or individuals listed on this form. ,rO ..•"..../'/v-.{I'..,c.,"..•••..../;P.!j;..,p""'~"7 .'X ....."./:...:...~-...~.t....-...~~;.J~~...",-:!::r-':_r-fl p -:-,I V-l£-//f'--:; ..;:..~••••"'"I ."-c,,~"t",".J •..,,~,~..'.•-"" "\'Signature01DODOf Dale(MMIOONY) '.',;.i~~...~;';~i.;';"L· I C.MRO Name,&Address y I certify that the specimen identified on this form is the specimen presented to me by the donor providing the certification in Step 8,that it bears the same identification number as set forth above and that it has been collected,labeled and sealed in accordance with the instructionsprO~!9~~;>".;~..~/"'''~....../{./'_""-...-"7--/..,~,.r».",/'.,.~..~.....»~.t.....,-..,//'-··,4;.p"·,...../'.•./~--.---....'V·''i2 -",t'"""rtl:x ,./"..:.:s U"-".-'_:$tJ~~~<..._."r-;"-'~,'(......~"~..-I Signatureof Collector Date(MMlDDIYY).--.----..---------..----.-.--.-.--.-.------.--.-.--.---..--.-----.----.--------..--f'-...---'"Collection Site Information: :\:I~.i-.f•::i\""~:i~'~·1:.."j' " ":f·::,....\',':~':..F~'~'!.'i ~j i...f:A,I.~:';'~-.'.;i':~1 ~."':~,:':;,,~~::s-,t~~,.n.c.::.!~y: I"""7.01''''''')?..,~~~:~~~~..:.,..?",_or '-'1 .r r:'l..,.'.....J"l'.•••;;;.,I'"._.~r.»":,..'~ ~"'.•.-,.."•..'"~~"'" ..':1,..::. D.B'eason for Test ;')"'~"". """,J;d..f?,e-employment 0 Random 0 Reasonable Suspicion/CauseoPostAccident0ReturntoDuty0Follow-upoPeriodic0Other(specify): E.Temperature Check _",..-'~ Temperature of the specimen read •••••8-"ye-s within 4 minutes of collection? o No ,.•~~~~~me·~-;~~pe~a~~~e~--r-·-·-sp8cimen 't;~perat~~;;S not Within ••••••.-between 90°and 100°F.I 0 range.I Record Temperature: F.Collector Certification &Information ".1-.:.':~.h ,'•••••':.<;:.~';.·1',:';'~'~'.::::.'~;..::'.:.:.:0·Ui.'~'1'~;'9 ::~".~,.If:~:"l"~ $.v;;.~,';:~'~"~;'.i_'::::~"i~'1!'-"«,Collection Site Phone No. ;.:l,":j .'.{';.'. ·1~.'?C Site 10 If G.On-Site Screening In!9rmation:To be completed ..by the person conducting the drug screen -I.••,-4~'/t'»:"<.~~~:~~.-----------l -------17~.·...i/.,.._J'-.c:;;.:,1,,J<~/.,/',..-,/-,.......•-~./l'/',G,.//1"7 ....".......,:Kit Lot No.:./"<._.c~/(_....•}/~Received and tested by:~,/-"':::>.,&-,,,,,,,,,·L >-"'/.._;.r....-·/..,:.-M~,..ij .''--'".•....,c !..'r'!_,•., ..-'_~;.:::;'-:/_<,~-Printed Name of Tesler •.•:'~SI Date (MMlDDIYY)!..f;2SRj!:9tj.QOJ;?§!~:_::'~_L.~:.~__...!~'!:.~~«.__ X.,·//.-;:;.'.•.'•.•--d.:>../.....•.......·OnSite Test Result:.ld~Negative 0 Requires Laboratory Testing"......,';..,.....,so"'""Signature ct'Tester --."-'."'-".,. Tester Remarks:_ Use Specimen Seal below to seal the specimen.(Send Copy 1 of this form with the specimen to ATN.)Released to:COURIER r.opy 4-I=MPI (")VI=t:!~()PV ~7'1' -.. ...:I<, ~lJ') rl'-- I I OJ ~I ~rl0!> EuyChJe(Tld)DIAGNOSTIC 2.19 (c)Ddd 2000-2007 $ll 639~1IleeNo\243 n.•.Iii':t,in.'fI..A.D Test Information Test Date/Time 04/02/10 10:47 .pI\<:r Tjmt> Test Mode InterpretationPredictedRe'f V"ll.lp C:;plprt. Tech ID Automated QCRTPS(TN/FXl DIAGNOSTICNLHEP NHANES III R!;C:;T VAIIIF ON -.--/1.0/ (Patient Information~.Name GREGORY ST LOUISTn!)?~I;~~Hll1h AgQ 36 Height 6 ft 1 in Weight ZB5 rbs ,BMI 37.4 r,~nrl~r MAl F Ethnic CAUCASIAN. Smoker NO .As.t.hma NO Ta.ctt_R~Rl,l]t:.S y[WI' Pre-Test Parameter Best FVC[L]4_60* FEV1[L]4.00 FEV1/FVC 0.87 PEFIll minJ 533 FEF25-75[L/s]5.29 FETls]6.79*Indicates Below LLN or nVl is M,t:Pf~.Qkt~(\ Tria13 Tria12 Trial1 4.55*4.60*4.55* 4.00 3.94 3.98 0.88 0.86 0.B7 ,533 538 552 5.29 4.89 4,94 6.79 7_15 6.38 Significant Post Change pred 5.93 4.74 0.81 659 4-48 %'Pred-----yg /' ~ 108 81 118 Pre-Test Interoretation FEVl Var=O.02L 0.5%:FVC Var=O.05L 1.1%;Session ~uality A Low vital canac t tv po s s tb Iy due to restriction of lunq vo l umes ~~ j'.%.j Legend --Pre-Test Tria13 ....".Pre-Test Tria12 ...........Pre-Test Triall ¢Predicted o~"'r--l'-'tr'l-'-r'-l 1 2345678volume[L]10mm/L 21 3 124 13 14 1556789lOTime[::;]lOmm/s 11 ~~ <:> 16 \....../ ~> ~.LI _ 12.Yes@ 13. Yes@:> Yes@) Yes@ OSHA RESPIRATOR MEDICAL EVALUATION QUESTIONNAIRE '-.' Have you ever had an injury to your ears,including a broken ear drum? r- Do you currently have any of the fol/owing hearing problems? a.Difficulty hearing b.Wear a hearing aide c.Any other hearing or ear problems 14.Yes@ Have you ever had a backinjury? 15. Yes ~ Yes ~ Yese@) Yes @ Yes t®? Yes 1@J Yes rQO> Ves @ Yes ~ '------'Y es ~ ITO THE PLHCpl Do you currently have any of the following musculoskeletal problems? a.Weakness in any of your arms,hands,legs,or feet b.Back pain c.Difficulty fully moving your arms and legs d.Pain or stiffness when you lean forward or backward at the waist e.Difficulty fully moving your head up or down f.Difficulty fully moving your head side to side g.Difficulty bending at your knees 'h.Difficulty squatting to the grnund i.Climbing a flight of stairs or a ladder carrying more than 25 Ibs. i.Any other muscle or skeletal problem that interferes with using a respirator.~-' Check v the ONE that appliestIhavereviewedPartASection 2 of this questionnaire with the employee and I do not recommend .that a physical examination be performed. I have reviewed Part A Section 2 of this questionnaire with the employee and I am recommending that a physical examination be performed.o I have reviewed Part A section 2 of this questionnaire without the employee and I do not recommend that a physical examination be performed.o I have reviewed Part A Section 2 of this question without the employee and I am recommending that a physical examination be performed. ~ I ut;~' CP Signature ~~Employee Signature (When Available) tJ l.f/tJ 1,-L).-rl/D Datb ("---./'-----...- TO BE FILED IN EMPLOYEE'S MEDICAL FILE _o£h:J_resp_"vQI Page 4 of7 Print Date: Revision Date: 02/16/2009 10/0612003 03/03/2011 LAST NAME GREEN FIRST NAME ALEX FIT TEST REPORT 10 NUMBER 9173 LAST NAME GREEN CU TOM1 FIRST NAME ALEX CUSTOM2 COMPANY SANDR CUSTOM3 LOCATION IDENVER CUSTOM4 NOTE TEST DATE 03/03/2011 PORTACOUNT SIN 80246025 TEST TIME 10:24 N95-COMPANION N DUE DATE 03/03/2012 RESPIRATOR 3M 6000 HALF FACE [100] PROTOCOL OSHA 29CFR1910.134 MANUFACTURER 3M PASS LEVEL 100 MODEL 6000 MASK STYLE HALF FACE APPROVAL NIOSH MASK SIZE MED EFFICIENCY 00:;99% N EXERCISE DURATION (sec} FIT FACTOR PASS NORMAL BREATHING 60 265 Y DEEP BREATHING 60 227 Y HEAD SIDE TO SIDE 60 250 Y "---./ HEAD UP AND DOWN 60 301 Y TALKING 60 305 Y GRIMACE 15 Excl. BENDING OVER 60 392 Y NORMAL BREATHING 60 365 Y OVERALL FIT FACTOR 290 y FITTEST OPERATOR ~. U~WIN ~ ____ ----~~ NAME .. __ DATE 5-]-/( /"'ALE GREEN STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Control Division This certifies that Joseph W. Karuzas Certification No: 13462 has met the requirements of 25-7-507, C.R.S. and Air Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Air Monitoring Specialist* Issued: 5/2112010 Expires on: 512112011 * This certificate is valid ollly wilh fhe possessioll 0/ a current DivisioJl-approved trailling course certificatioll ill the discipline specifled above. TEST DATE 07123/2010 PORTACOUNT SIN 15469 TEST TIME 09:21 N95·COMPANION N DUE DATE 07123/2011 RESPIRATOR 3M 6000 SERIES HALFFACE PROTOCOL OSHA29CFR1910.134 10 MANUFACTURER 3M PASS LEVEL 100 MODEL 6000 SERIES MASK STYLE HALFFACE APPROVAL NIOSH MASK SIZE MED EFFICIENCY <99% N EXERCISE DUBATION (sec) FIT FACTOR PASS NORMAL BREATHING 60 4950 Y DEEP BREATHING 60 3970 Y HEAD SIDE TO SIDE 60 6310 Y HEAD UP AND DOWN 60 5740 Y TALKING 60 4620 Y GRIMACE 60 5070 Y BENDING OVER 60 8630 Y NORMAL BREATHING 60 4620 Y PAGE: 1 SAFETY Remit to: Total Safety U.S., Inc .• P.O. Box 974686. Dallas, TX 75397-4686 For Billing Inquiries Call: (303) 766-1501 ~,dP TO: S & R ENVIRONMENTAL ***CREDIT CARD 1 COD ONLY*** 5590 HAVANA ST, UNIT A DENVER. CO 80239 SALES INVOICE ATTN: C#:303-297-1645 J#: 303-297-1645 BILL TO: 11124 S & R ENVIRONMENTAL ***CREDIT CARD 1 COD ONLY*** 5801 LOGAN ST STE 200 DENVER. CO 80216 Qty Unit Item numberlDescription 1 EA FITTEST FIT TESTING JOE KARNEY Shipping & Handling JOE KARNEY 303-297-1645 Invoi ce # ... System date. Date out .... Invoice date Job Loc .... . Job No ..... . P.O. # ..... . Ordered By .. Ship date .. . Ship Via .. .. Terms ...... . PAYMENT HISTORY r---DATE-TYPE-- 7/237IU VISA REF # AUTH # TRANS TYPE **2948 UH34I1 CHARGED--- The Best Minds in the Business! Standard payment terms are: Net 30 Days from the date of invoice. Any claim for shortage must be made In writing within 10 days after delivery. Written afprova' ref:luired for returns prior to 30 days from the date 0 this invoice. There is a restocking charge on aft returned items. No material accepted for credit after 30 days. Cust Unit Name: Cust Proj/Job Name: Cust WO / Jobft: OCSGft : 4574809-0001 7/23110 7/23/10 10:32 AM ***CREDIT CARD 1 COD 4 -S & R ENVIRONMEN CC 7/23110 DELIVERY Net 30 Unit Price 30.000 SUb-total :$ Total :$ AMOUNT ------ Amount 30.00 30.00 30.00 APPLIED --3U-:-UU mp: CBENEGAS 0 E N Concentra Medical Centers 420 East 58th Ave ~Ie 111 Denver, CO 80216 Phone: (303) 292·2273 Fax: (303) 296-4138 ( Physician Respiratory Examination Record Service Date: 0710912010 Patient Name: Karuzas ,Joseph W Address: 705 S Memphis Way AURORA CO 80017 SSN: XXX-XX-1577 ! EXAMINATION! Height Weight Pulse i~~1f Temperature Blood Pressure Respiration Heart , ''1gs I 1\ s Ear Drums Nose Buccal Cavity Pharynx Musculoskeletal Hernia at performed at DPass DFaii 7<£ AB AB AB AB AB Concentra Medical Centers DReturn to Clinic on _____ --'At: am/pm ICI 's \N\)1:VU Gender: Male Day Time Phone: (303) 297-1645 x Night Time Phone: (303) 880-1093 Race: (Circle One) Asian / Black / Hispanic Indian / White / Other Employer: S&R Environmental Consulting !TESTINGI Testing necessary for 29 CFR 1910.134 does not Include testing n€cessalY for other OSHA medical surveillance: EKG Performed YES (§) • Comments __________ ---c= __ _ @ Spirometry Performed NO • Spirometry Results Attached ~ NO • Comments: ----------------~=------@S Chest x-ray Performed NO • Results: WNL YES NO • # of views • X-Ray # • Comments: _____________ ---c,--- B-reader Required YES ~ • Date sent: • Results: Vision Testing • Right Eye • Left Eye • Color • Depth Perception • Peripheral L8(jC', R -90 I " Audiometric Test Ordered YES ~ Within Range Out of Range • Results: • Comments: ----------------~~~---@ NO Blood Tests Ordered • Tests Ordered: • Results: '-------cI-=-r.;:::it:--h:--in-cR=-an-g-e--=O-u-t -o-=-f ~R-a-n-g-e Urinalysis Ordered • Results: • Comments:'---_________ --===-__ @NO Out of Range Within Range • Comments:'---____ --,--:_--;--;;""' ____ _ .C:::f.\O () ~ II', t r.~, ~. \M hi.' d v,"' -'\ '-4. \ ,0\ Q "" 't" ~hr\i~,1-' ~ To be maintained In employee's medical record . Physician's Name (print) Page 1 of 1 Print Date: Revision Date: 0.:1 ucoJ' 07/09/2010 06/29/1999 420 East 58th Ave Ste 111 Denver. CO 80216 Phone: (303) 292-2273 Fax: (303) 296-4138 r Concentra Medical Centers , EMPLOYER AUTHORIZATION AND INFORMATION FOR RESPIRATORY EVALUATION II r-_.,PLOYER TO COMPLETE THE FOLLOWING: I Employee Name: Karuzas. Joseph W. Employer: S&R Environmental Consulting ©heck Type of Respirator(s) To Be Used ItCheck vALL that apply) I D Air-purifying (non·powered) DAlr·purifying (poweied) DAtmosphere supplying Respirator o Combination air-line and SCBA o Conlinous-Flow Respirator D Supplled·Air Respirator D Open Circuit SCBA D Closed Circuit SCBA o Dust Mask 0112 Face with Canisters 0 Full Face with Canisters Make: Model: Cartridge: ~~~~_ pecial Work Conditions Check v ALL That Apply When Wearing Respirator) o High Places D Enclosed Places DTemperature Extremes DMostlyCold DOther:~~~~= _____ -=.--_,----.=-__ _ o Protective Clothing o Moslly Hot Questionare will be: D HAND CARRIED D MAILED D OTHER Address: 705 S. Memphis Way =A~U~R~0~RA~.~.--~~.--__ ~C~0~ __ ~80017 Employee SSN: XXX·XX-1577 "xtent of Use age I iCheck v ALL that apply) o On a daily basis ~~ Tolal Hours o Occasionally -but not more than twice a week __ Tolal Hours o Rarely -or for Emergency situations only __ Total Hours "xpected Physical Effort Required I kCheck v ALL that apply) I D Light 0 Moderate D Heavy iEx pas u re to H a .ard ous Materia I s I X"'C"hcceC:c"k-v"A'L'L-CtOChCCa tCCaC:p::p"'ly")'1 o Arsenic 0 Benzene D Coke Oven D Callan Seed 1 Dust D Cadmium D Formaldehyde D Methylene Chloride D Lead D Textiles D Chromium· Other(s): _~~~~~~~~~~~~~~~_~ EVALUATION AUTHORIZATION BY: --c-----.".-- Signature of Employer Representative DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE PLHCP 1 WRITTEN STATEMENT for RESPIRATORS (EMPLOYER) !,hH"'yC;;S"'IC;;:I~A"'NccW'"I"'"L L~C""0-;;M"'P:;-L;o.ET'"E~T'"H7;EO-;F"'0'"L7L~O""W:;;IN"'G"'I ( report may contain confidential medical information and is intended for the designated employer contact only. The Americans with Disabilities Act \\ ) imposes very slrict limitations on the use of information obtained during physical examination of qualified Individuals with disabilities. All Information h,u$t be co!Jecled and maintained on seperate forms, in seperate fifes, and must be treated as a confidential medical record, with the following exceptions: " Supervisors and managers may be Informed about necessary restrictions on the work or duties of an employee and necessary accommodations. • First aid and safety personnel may be informed, when appropriate, if Ihe disabilily might require emergency treatment. Based upon my findings, I have determined that this Individual tCheck '7 ALL that apply) I g~ployee must schedule a medical examination with Concentra Medical Centers MCIass I • No Restrictions on Respirator Use o Class II -Some Specific Use Reslrictions 0 To be used for Emergency Response or Escape Only o Class III -Respirator Use is NOT PERMITTED o Further Testing I Evaluation is Required. 2 o Fit Tes"! Required 0 Fit Test Performed Satisfaciorify prior 10 respirator approval and usage, o Olher:~~~~~~~~~ o Fit Tesl Performed Unsatisfactorily 0 Fit Test NOT Performed at: Con centra Medical Centers DSpecial prescription eyewear needed to accommodate respirator 0 Special prescription eyewear needed to accommodate respirator o Facial hair needs to be shaved to assure tight seal on certain face masks. 1 Physicianor other Licensed Heallhcare Professional 1:mployee must seek further medical evaluation by a private physician who must submit a report to Concentra Medical Centers of hislher findings 10 -' !Che~v ALL that apply) I -o The above individual HAQ..been examined for respirator fitness in accordance with 29 CFR 1910.134. This limited evaluation is specific to respirator fu use only. Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. fi 1'.rJQ This evaluation Included the Respiratory Questionnaire outlined in 29 CFR 1910.134. 'V ./ o The above indiVidual H..AS..NQJ been examined by me for respiratorfilness. The employee's medical evaluation consisted of a review of OSHA's Medical Evaluation ~ Questionnaire in AppendiX C Part A Section 2. In accordance with 29 CFR 1910.134, this Ilmiled evaluation is speCific to respirator use onty. Employees would b~ to re r( any difficulties in using respirators or change of any physical status to thelr supervisor or physIcian. This evaluation included the Respiratory QueSUOnnair"l~1A (YOf1 Uinedln29CF 1910.134. -, In accordance i! specific OSHA require s, I have informed the ab' med individual of the resuns of this evaluation and of any medical conditions resuHing fr or treatment. W applicable, the above named indIvidual hss been informed of the increased risk of rung cancer , read and/or other chemical exposure(s). hlysician Page 1 of 1 Print Date: 07/09/2010 To be maintained in the employee's file with a copy to the employee Revision Date: 0612911999 Con centra Medical Centers 420 East 58th Ave Sis 111 Denver, CO 80216 Phone: (303) 292-2273 Fax: (303) 296-4138 J PLHCp1 WRITTEN STATEMENT for RESPIRATORS (EMPLOYEE) Service Date: 07/09/2010 -===-'-'''----- Employee Name: Karuzas. Joseph W. Address: 705 S. Memphis Way AURORA CC 80017 Employer: S&R Environmental Consulting Employee SSN: XXX-XX-1577 You were evaluated in this office of your medical status related to your physical capability to wear a respirator. (Check../ one that applies) ~e were no abnormal findings that would'hamper your ability to perform your job duties while wearing a respirator. o The abnormal findings listed below were not related to wearing a respirator but should be reported to your personal physician for further evaluation. BasyKupon the results of this evaluation it is my opinion that you: (Checkv' ALL that apply) EARE qualified to wear a respirator. o Have the following restrictions concerning respirator usage: o ARE NOT qualified to wear a respirator. ( --qequire further testing by your private physician who must submit a written report of his/her findings to . '::oncentra Medical Centers so that a final decision on your ability to wear a respirator can be made. o Must wear Special prescription eye-wear needed to accommodate respirator. o Must use an Eye glass conversion kit. o May need to shave Facial hair to assure tight seal on certain face masks. o Need to stop smoking. ~ that apply) he above individualHAS.been examined for respirator fitness in accordance with 29 CFR 1910.134. This limited evaluation is specific 10 respirator use only. Employees should be instructed to report any difficulties in usIng respirators or change of any physical status to their supervisor or physician. This evaluation included the Respiratory Questionnaire outlined in 29 CFR 1910.134. o The above individual HASl.::lQJ been examined by me for respirator fitness. The employee's medical eva!uallon consisted of a review of OSHA's Medical Evaluation Questionnaire in Appendix C PartA Section 2.10 accordance with 29 CFR 1910.134. this limited evaluation is specific to respirator use only. Employees should be instructed to report any difficulties in using respirators or change of any physical status to their supervisor or physician. This evaluation included the Respiratory QuesUonnaire outlined in 29 CFR 1910.134. o In accordance with specific OSHA requirements, I have informed the above named individual of the resu!ts of this evaluation and of any medical conditions resulting from exposures that may require further explanation or treatment. Where applicable, the above named individual has been i.nformed of the increased risk of lung cancer allribulable to the combined effect of smoking and asbestos, lead and/or other chemical exposure{s). RespIrators must be properly sefected based on th contain nt and concentration levels t ' Ich the workerwfll be exposed. Failure to follow the use and fittIng instruction and w nfngs for pro er use contained on the res ator pa ging and/or failure to wear e res ator during all times of exposure can reduce the respIrators effectiveness an res It in slclm or death. Wearer must be fined in t, proper care of any resplrat r.Refer to roduct literature and packaging for specfflc Information regarding flf, u and r limflat s. PL CP lCP Name (printed) Expiration Date 'Physician or other licensed Healthcare Professional To be maintained in the employee's file with a copy to the emp oyee Page 1 of 1 Print Date: 07/0912010 Revision Date: 04/06/2000 r ,e: Karuzas, Joseph W. Concentra Medical Centers 420 Easl58th Ave Sle 111 Denver, CO 80216 Phone: (303) 292-2273 Fax: (303) 29S-4138 Physical Exam SSN: XXX-XX-1S77 Examination Results __ Able 10 perform essential functions as listed. Service Date: 07/09/2010 Date: 07109/2010 __ Unable to perform all essential functions as listed. Please list failed essential function(s): z ( No medical. restrictions are indicated. ___ The following medical restrictions are indicated: ( Recommend further evaluation. Remarks: Eval • Pre-Placement Page 4 of 4 © 1996 -2010 Concentra Health Ser.ices, Inc. NJ Rights Reserved. Provider Signature Revision Date: 01/24/2010 ;1 ,( Patient Infonnation Name JOSEPH KARUAS Tn Fi?lAlllfi77 Age 54 Height 5 ft 5 in Weight 179 lbs. BIH 29.8 (;pnripr flAI F Ethnic CAUCASIAN Smoker NO Asthma NO Test: Results, Y,OJlr FEV] is 93% Pr.edicte.d PI'e-Test --P.arameter Best Tri a 11 Tri a13 Tri a 12 'FVC[L] 3.21* 3.21* 3.14* ~* FEVl(.LJ. 2.95 2.90 2.95 2.86 FEVI/FVC 0.92 0.90 0.94 0.93 PEFfLlmi n] 452 452 438 412 FEF25-75[Lls] 4.72 4.72 4.48 4.17 FET(.s]. 3.60 3.60 3.42 3.18 Test Infonnation Test DatelTime Pn<::t Timp Test Node Intel'pretation PI'edi cted Ref V;JlllP.Splp('t Tech ID Automated QC RTPS (TH/FX) Pred ZPred 4.13 78 3.19 93 0.77 120 511 80 2.82 167 --- * Indicates Below LLN or Significant Post Change &l.sJO~e{TM) DIAGNOSTIC 2.19 (e) ndd 2000.2007 SN 63921 Rc.:No 1388 07109110 10:20 DIAGNOSTIC NLHEP NHAN ES I II RFST ·VI>IIIF ON -.--1 1.0? PI'e-Test Interpretation FEVI Var~0.05L 1.7%; FVC Var~0.07L 2.2%; Session Quality A " ----..:l :. 0 .-j '" Low vital C.a.Qa.city possibly due to restriction of lUn9 volumes 14 "-'r-T' If'r--'r--'I 12 .. _.-....... 1-.. -........... ~ .. -... ······~.I+ ····· ... ,1-·_·1·········.-... ·.·.· ....... ,1 , ......... _ .... ,i ... ___ .1_ .... _ .. _ ················,1-;--.. - I I .... ,1 ............. ,f~ ; ..................... ,i---.~ ... --I ' '.:t .... \ .. r .. _····· ···-1·-.. ~ ....... ,! _ .... -.... -~ .. -... -..... 1.·.-.... ·.·.·.·.·.·.·.·.·.·.' ......... ,1 .. __ .. -.--.".C;~~:~:-.... ,-............. 11/.--; ~ !! ! r" i ! 1 6' 4 . ·· .. -1 .: " o '-_'---_'--_""--._ .... _ .... ~r)_·· _··..if_···_· ---'_........i''---'' 12345678 Volume[L] 10mm/L 2 ---Pre-Test Triall --_. Pre-Test Tria13 ........ Pre-Test Tria12 <> Predicted 8 ............. , .............. ,........ ....... . ....... -........... -... , ...... -........ -..................... . ................... , .. _ ........... , ........ . 1 -i j ; :: 1 ; .; F--=l 7· .. ····-·· i I . : ....... _ ..... i_ ....... _ ..... ~ i ill .. 1 .; t ................ ,1 ____ ~ ""'1 .... · ...... · .. ·T· .... -·-· .. · .. ~ ...... ··-·-·· .. ~,l·· ........ r! 1 "'''''''''''',('' ....... ; ........... ·.·.·.·.·.·,:1.· ... · .... · .... · .... l .... ·· .... _· .. ··C· · .. ·· ..... l .......... ·_ .... ·! . .. . ............ _'....... . .. . 6 ............ · .... ·1 ... -r ...... ···· ........ ,1 .. · .. ······ .. · .. 1 ................... ,; ................. j .. -..... 1".. . .. ;" ............ · .. -l-...... ..·· .. ! .. · .. · ........ · ..... ,i· ...... · .. · ...... ·~,; .. ·-...... ·.·.·.·"' ... ,1 ' ...... ,!_ ...... _ . , ....... ,1......1 · .. ··:.:1 >0 5 _,... ..L....... .. ......... ,L ; , i -> • : ........... __ .. 1 .... _._ .. . • ... _.!...... .. ...... _ .... !............ .. ... · .... 1 .. · ...... · .. · .. ·t-.... · .. ·t·· .. · .. · .... · .. i ... · .. ·· .. -.. ". _ ......... _-;-................ ! ; ...... !.._ ........ _ .. .L ....... _ ..... ,1,1_ .... <> 1 ................ ,._._ ..... __ J .. _ .............. L ........ _ : ; . i ,--· .. ' .. ,i .. · .... ·_ .. ·_ .. ·!.... ..····-.. ,1 .......... -.. -·~ --!"'--" ....... ~ ... -...... -... ~ ........ , 1 i 1 1 : i 1 ! ............... ,1 ..... 2 .. __ ... _ ... _._ ....... -!-_ ............. ., ................ L. .. _ ........... , ................. ",!._ ..... _ ..... ~._ ........ _.~ ........ -..... 1 ................ ~ .... _ ..... _ ...... . < i i ......... ,'--!;:. . .. 1.. 1 ... ~." i ... _L ................ L.... .. ........................ __ ........................ 1.. ............... ..1... .. ........ -.... .... . ... ······i.. .. .. -........ t,............... 1 .._.~._ .... _ ! ............ i,'... i ............. ~ 1 L... I ! ....... ~.-: ....... --..... ~ ... -.. -... .. .......... _:: ... ,1 "f'" · ........ · .. · .. ·1---.. ···.... .. .... ··r·-· .. -...... ~· .. -··.. "'r ..:l 4 _ ........ Ql 3 .......... ~ 2 .... .. .-j 0 1 ~> 1 2 3 5 6 7 8 9 10 Time[s] 10rnlll/s 11 12 13 14 15 16 ( Advanced Toxicology Network ~560 Air Center Cove, Suite 101 Memphis, TN 38118 Ph: J8881290-1150 Fx: (9011794-6460 Medical Director: Pamela T. Osborne, MD Patient Name:' Patient Id: Al ternate 'ld:' 'DOB -Sex:- Phone: ' Requisi tion: Collected: Received: Reported: Fasting: KARUZAS, JOSEPH W 400969972 400969972 7/9/2010 -M 400969972 07/09/2010 11:10 07/10/2010 05:15 07/1212010 07:57 N ' 100709KIFL01 Account: Address: Phone: Location: Physician: Report To: Address: Phone: Fa){: 400969972 *06420 *06420 CMC/Oenver- 420 East 58th Avenue Hill Denver, CO 80216 (3031292-2273 ' S & R ENVIRONMENTAL NG 1770 *06420 CMC/Denver-No 420 East 58th Avenue Hl11 Denver, CO 80216 (3031292-2273 13032964138 Collect Site: 1770 *06420 CMC/Denver-No Phone: (3031292-2273 Post-Prandial:N/A ================================================================================ ( Advanced Toxicology Network 3560 Air Center Cove, Suite 101 Memphis, TN 38118 Ph: (888)290-1150 Fx: (901)794-6460 Medical Director: Pamela T. Osborne, MD Patient Name: Patient 1<1: . Alternate Id: DOB -Sex: Phone: Requisition: Collected: Received: Reported: Fasting: KARUZAS, JOSEPH W 400969972 400969972 7/912010 -M 400969972 07/09/2010 11: 10 07/10/2010 05:15 07112/2010 07:57 N . 100709KIFL01 Account: Address: Phone: Location: Physician: . Report. To: Address: Phone: Fax: 400969972 *06420 *06420 CMC/Oenver- 420 East 58th Avenue nl11 Denver, CO 80216 (303)292-2273 S & R ENVIRONMENTAL NG 1770 *06420 CMC/Denver-No 420 East 58th Avenue nll1 Denver, CO 80216 (303)292-22.73 13032964138. Collect Site: 1770 *06420 CMC/Denver-No Phone: (303)292-2273 Post-Prandial:N/A ================================================================================ TEST RESULT FLAGS NORMALS UNITS i ( RESPlRA TOR FIT TEST FORNI NAME ' ~e.. KQS\,/7,O\S DATE,------<:%-.L0~'R~3..l_)__.:):....:0~ __ " EMl'LO),ER,_--".)),--i,,--,~-,--_--,=F=J\D-!)""}LL; .L-r.1.<OCLn~'-"'--'!I'\,,-d''->''',,-+l_ LO CA TWN,_--,=D=--::::Cvv0=o::'f!.~")£c=--__ _ ,TOTAL SAFET), IN,c;TRUCTOR,_--,=:=\=-:o=-:~,--_-,L~eJ=-~ __________ _ Answel' the followiog questiomlJ)'ehecl<ing the opl'l'ol'l'illt" YES rH' NO .9fl"CC, 1.~YES __ NO Hovt .1'011 filled out n Medicnl Qucr.tionl\ail'c nnrl been Fit Tested by" certifyillg "ciivi!)' within the past 12 months? ln NO, a Medical Quesl'ionnaire and subsequent Medical Evaluation must he conducted pl'iOI' to administering a Qualitative 01' Quantitative Fi.espiratod'it Test, ' Z, __ YES ANO Do Y~U'II"Ve an)' facial Jlail' 01' an)' fadal cilaracterisiics that would interfere with the sealing edge of a respirator face piece? 3. __ YES ~o Do you need a speeiaele kit? TYPE OF RESPIRATOR X AJRPURIFYING --kSUPPLIEDAIR ASELFCONTATNED MANUJ7ACTURER,_---'·3~fVlc...::...l ____ lVJODEL'___.......g.6L10.4.l..(24t=')'-----_-:......_ STYL.E,_' __ I-I-H.....I'P'----------, SIZE'------LM~l:::S:.JO~ _____ _ , -t,NEGATll'EPRESSVRE -hPASS __ FAIL ApOJlT-A-COUNT _mmex, ,){PASS SEAL CHECK 1POSITIV E PRESSURE -X-PASS __ ,' FAIL FITTEST __ lSOAMYLACETATE __ SACCHARIN !TOUTANT SMOKE __ J7/lJL 1 certify thaJJ hm'e heen trained this date in norma) and cmerg'cncj' operation and use of the ,~pi"toc, h~ t. get' P',po ",' with "" f'" pi", '" d :W ~ w;:;, i"'J"" ,,' cJ~p th" upit ~~1(MyA0-~ E PLOYEE SIGN TURE RUCTOR 81GNA.TURE ( 3032529474 Occupational Medicine & Rehabilitation at North Suburban 08:33:27 a.m. 09-30-2010 9195 Grant Street Suite #100 Thornton, co 80229 Phone 303·292·0034 Fax 303·292·0097 OSHA ASBESTOSIHAZARDOUS MA TERlALS/ RESPIRATOR CERTIFICATION Tn accordance with OSHA regulations 29 CFR 192.58 Asbestos 29 CFR 1910.120(1) Hazardous Matenals 29 CPR 191O.l34(b) Respirator Certification The examining physician will provide the employer with a written opinion, which shall contain the following: This is to certifY that on this date: 1-[5-to, and in accordance with the regulations as indicated above, I have perfonned a comprehensive examination on JVATftt'=-'l.v q t,N V1s;J13vhose social security number is SJ.)' -/> GI/<? Base on ~y findings, I have determined that this individual: _-;-,,/~.MAY ___ MAY NOT wear a respirator or device while perfonning his!her required work tasks, and IS __ IS NOT medically cleared for work with_ASBESTOS HAZARDOUS MATERIALS. The resnlts of my examination: ___ Have ---....-:::::.-n:v: NOT detected a medical at increased risk of material health impainnen! from ___ Respirator EqUipment ___ .ASBESTOS. IN accordance with OSHA requirement, I have fully examination and laboratory tests to the above named Comments: A complete medlc.al examinlltlon on the above named Individ " 1nrlit~d~d 10 lite employer pending finall'eview and interpretation orany J nal.m2 collected. L~~·~ Examining Physician Arthur Kupor 0. O. 9195 Grant St., Bfa. #100 Thomton, CO 80229 303·292-0034 2/3 ( Qualitative Respiratory Fit Test I Name: }1q!r S;~ Date: ICJ-/-/0 I SS#: W"/q Respirator Type: Manufacturer: Model/Type: It" 1£ L: r? IlJcl~,k...., ?)f?o4YIYJ (iJ--Review Test Protocol Ii4'1;mell weak concentration of irritant fumes(response) ~)Year at least ten minutes prior to start IB"'JositivelNegative pressure fit test Ia" Breathe normally ~'eathe deeply u:r .Jurn head side to side and up and down ar.Jjpeak "The Rainbow Passage" E1 Jogging in place "The Rainbow Passage" Approval Number: Sill iJ __ '~AJ "When the sunlight strikes raindrops in the air, they act like a prism and fOlID a' rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends apparently beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow." This document certifies that the above person has been given a "Qualitative Fit Test" for the respirators listed above as specified in the 29 CFR 1926.1101, the OSHA Constmction Standard, Appendix C In'itant Fume Protocol. Test Administrator Sigllatllre/Date: ~ ~.-c:>:::::: ? Test Subject Signature/D~~ h ~/t"-IO GOBBELL HAYS PARTNERS, INC. 10500 East 54th Avenue, Suite J .:. Denver, CO 80239 Ph. (303) 574-0082 .:. Fax (303) 574-0061 CERTIFIES THAT MATTHEW SNYDER Has successfully completed The 40 hour EPA-APPROVED AHERA ASBESTOS COURSE for Contractor/Supervisor and has passed the required exa.r:nination in that discipline. This course is EPA-approved under Section 206 ofthe Toxic Substances Control Act CTSCA) and meets the requirements of Colorado Regulation No.8. Gobbell Hays Partners, Inc. purchased MCA Enviromnental, Inc. and course approval can be found in the EPA directory under MCA Environmental, Inc. listed as training provider #931. Course Date: 6/21110-6/25/10 Exam Date: 6/25/10 Certificate No.: 6/10CSGHPl Expiration Date: 6/25111 ( ( INTERNATIONAL Environinental and Safety Training L.LC. 720 Billings street Unit F Aurora, Colorado 80011 Phone # (720) 859-3134 Fall # (720) 859-0660 GILBER.T LUCERO Has successfully completed The EPA-ApPROVED AHERA ANNuAL ASBESTOS REFRESHER COURSE for SUPERVisOR And passed the requirements examination in that discipline This course is EPA-Approved under Section 206 of the Toxic Substance Control Act (TSCA) Course Date No. Hours Celtificate No. 08/21110 8 C008211 0-01ASR 08/21111 This course meets the requirements of AQCCReg.#8 Instructor Name: Horacio Cuevas ( ( INTERNA TIO NAL Environmental and Safety Training L.LC. 720 Billings street Unit F Am-ol-a, Colorado 80011 Phone # (72()) 859-3134 Fax # (720) 859-0660 GILBE.RT ,LUCE.RO Has successfully completed The EPA-ApPROVED AHERA ANNUAL ASBESTOS REFRESHER COURSE for WORKER And pass,ed the requirements examination in that djscipline This course is EPA-Approved under Section 206 of the Toxic Substance Control Act (TSCA) Cqurse Date No, Hours Celtificate No, Expires , , , . ~ ~ ! f ~ . ..,.; . 1!l\~J.Jid without rai~d ~e-aJ 11114/09 8 CO 111409-03A W 11114/10 This course meets the requirements of AQCCReg, #8 ~AUL Oli~DS PAGE 04 .' Pf~jed Name:' ':." -' - . RESi""JRAiOR F1Fl'EST SUMMARY . (A ,i,eparate FftoTest 11WSt b~ pC)r{ormr;;d foi' each Ne'gatjV~ PrC)s$urf) Respfrotor iis$d) . . SigITa1wre of ,Person Performing r;i-Tes,: RE8Pjg."~-RJ.\-·c',!"'N-rN-G-R-· -~-C-O-R'-D-~-------' Your s:gr.ature on this Raspirator.Traif1lng Record will attest to .your having received and understood the followIng respiratoi t,alnlng informaHon which both OSHA and Eliie require "s a yari of their Respiratcry P<,otection Program. (be :,=qUiH~d respirator trEdning consists of the following infcrmatlon: An explanation ';f the prooiems Involv~d ill mlsusir1g or inter-changing parts of the respirator. A discussion of why engineering controls could not.pfev-sni the use of (espjratof'J protection. How. and why this make and model respiretor was chosenJorlhis specific proJect.. The limitations of ihis make and modei (e.spi(ator . . How to put on this respirator and properly adjust the facepIsce. and tension straps. How to wear this respirator properlY· Wh~t the essential points of the care and maintenance of this ~espl!dtor. are.· . How to recognize aod handle emergencies Nhich may occur while using this respirator. How to properly in~pect. clean a.nd disinfect this respirator. How io properly use an Air-Purlfying Respirator. When a Powered Air-Purifying Re~pirator is required. When a ·Yype-C supplied-air respi,'2(o( ;s ""quired. The oumose of the medical evafUarlon. .. "," How' ~jjte periorms a p~oper. respirator fit .. test. in?£ this fit-test must be performed anousify. That you will be permitted,to leave the work area to wash your face and r8spira~O( woe-:lBVer nec6saQ~'. That filter elements mai be changed whe.neve~ an increase in breatn!ng-resistance is cetected .. That a Powered Aif-Puijfying Respirator (PAPR) is available to.you upon request, .es long as!t masts the protection factor for the hazard ir:vclved .. Employee Signature: A~~~.-·,,--Date: / !/M ~ '. . : .. " .,:.- ( PHYSICIAN'S WRITTEN OPIN10N -ASBESTOS Applicant's Name;~VfIl........:...t/W{}-.:.....::~Gi:::....·....;Il?_tY~q ~--,-...c......~ ______ _ "TIll> above named individual was seen by me on 5 -' I 0 -. i 0 '. and In accordancs with all applioable portions of OSHA's Asbestos Standard fDr the Cansiroolion Industry, :19.CFR 1920.1101, with whiah I am famJ7ier, I have indiC8/ad by my fniUels, that I have petfonneli the fallowing:" 1. & <' Reviewed with this individual, his/her completed OSHA standardized Me.dlcal Questionnaire end Work History, directed towards the pUlmonary, cardiovascular, and gastrointe<;tinal system: and 2. aLL 3. W 4. 0..0 .'-~ .. ,- 5. (}L/ B. at/ 7. &/ B. tiU!./ Reviewed the employer's descripllon of thIs individual's duties as they relale to asbestos exposure. the anliclpaled exposure level, the parsonal protectlvEland resplratory equipment to be utilized by thEl indiVidual, snd any addiHonel medical information resulting from prevIous eXaminations; and '.' Conducted a physical 8K<lmlnatlon of this Individual with emphasis on the pulmonary, cardiovsscular, and gaslrolntesUnat syslems, InGludlng a pUlmonary function lest of forced vital capacIty (FVC) and forced Gxplratory volum(l at one second (FEV-1); and Determined that a chest roentgenogram was 0 was not Ef'reqUfred as a part of thIs elG3mlnatlon. (If requIred, the x.ray was lakenand reOld In accordOlnce wIth Appendix E of tlie Asbestos i)w.ndarrJ)osnd DetermIned that this IndivIdual may ®mal' nol 0 US~~-:~PI;a;Ory ~~~i(): ~hH~­ psrformlng hlsiher requlrecl employment sBIVlces; and Informed this individusl !hOlt I have 0 have not ~eteoted a medical condition which would plaoe this individual at an Increased risk of materlal health impairment from eXpo5ura to asbestos; and Informed this IndiVidual of the results of my examination and of any medical condition that may result from this Individual's exposure to asbestos: and Informed this individual of the health rl"ks Involved In smoking, of tha synerglstlo relationship between cigarette smoking and asbfi5!OS exposure In produCing lung C<lncer, end Ihat cessation of smoking will reduce the risk of lung cancer. Comments andior LImitations (If any): (Physiolan's Ptinlod Ntime) ~e3:S?'"9I-CW1o {PhyslatBn's PhOM No.} (Phys(,ian's Add", •• ) [ ORIGINAL TO LVI OFFICE: -COpy TO JOB SITE:" COpy TO EOMPLOYEI::j Amelia Garmosino, M.S., p~"Cr W 26th Ave., Bldg. 0 SUIte < 2420. CO B0211 Denver, 303-831-9393 " • ".,. •• \ I .,. " .. ( ( / ./ ./ ,.-_.-.-_ ... ... -_ ... --_.- PERMIT.REQUIRED CONFINED SPACE .WORKER THAINING COURSE 311 ,'r@~~~cg,~~:~~;C~OMPLETION OF ~ 1910.146 .. ~~---~~-~--.--.--.~. 80. HOUR HAZARDOijS WASTE TRAINING COURSE . ... ~;f"·It,· -.f2/Ptfrff ffaq. Instructo iralnlng OI($I.clor O.ate ; ASb""""'J G.f'r·~ nll.hh-r:t/ 12-/15 Certificate cif'Training Coforacfo Laborers) and Contractors) iEaucation and '['raining Puna '['his is to certify that GILBERT LUCERO lias successfu[[y compCetecf tfie course requirement for aD-Hour Hazardous Waste Worker on OCTOBER 24, 2008 ------------------~------------------- OCTOBER 24, 2009 ~ "iflStT\;ctor(s) DirectO;:oTraining 58593601141311008 Certificate Number Complies with OSHA Regulation 29CFR1910.120 10505 Havana· Brighton, CO 80601 • (308) 287-3116 INTERNATIONAL Enviro.nmental and Safety Training L.LC. 720 Billings street Unit F Auro.ra, Co.lo.rado..80011 Pho.ne # (720) 859-3134 Fax # (720) 859-0660 dOReR HERNANDEZ HaS successfully completed The EPA-APPROVED ARERA ANNuAL ASBESTOS REFRESHER COm.sE for SUPERVisoR And passed the requirements examination in that discipline This course is EPA-Appro.ved under Section 206 of the To.xic Substance Co.ntrol Act (TSCA) Course Date No. Hours Certificate No. 01107/11 8 C00107I1-03ASR 01107/12 This course meets the requirements of AQCCReg.#8 Instructor Name: Horacio Cuevas, ASBESTOS PHYSICAL FORM n"'~"""'4!JJI~W <>"4 jl .... ""'<ln.,'"' (_oW Patiuu H:a:tne: (4 tz:rZ,,,'f\ 1\)~11 1"'(W~ss:;~t:6995-1 B~6~~8"7z I""': -SO";C,L '3f5' , Strut Addrus: ::::L City: Su.u: 1 LOt> CO~ 0 "l 'Z~ ,-<)700 w.: ~v~ LI-I-k r£-lA.! Nt\, en HonUl; Plou~: M'uiw Sb.tUJ: VJ)ute~i.a.nCl bl.d.iu1O Bl;..c).:C '.5 (tllbL IE _ Hisp' Otrel"C ErnplOJ-E:r: Oecupation: WotkPh~ne E:rnployer·s Addnu Please check the appropriate box: Complete A, S, C as noted Asbestos Physical 0 Complete A, Band C Respirator Physical 0 Complete A&B Only PART A: Medical History PARTB: Family History PART C: Asbestos History (Supplement to respirator questionnaire) Were either oryour nnturnl parents e\'cr told Do you currcmly, or have ),ou in (he past ./ by a doclor that th~y hod a chronic lung worked in these industries? Have you ever smoked? ~ No condition such as: How much per day? 10 Father Mother y N YEARS Have you quit smoking@@) No y N NA V N NA Worked in a mine? I' Chronic / { Worked in a foundlY? ( If yes, indicate date qu t I bronchilis Emph}"Semll I I Worked with polte!),? { Do you consider yourself in good Asthma / i7 Worked in conon or I health? @ No Lung C:mctr / / Flax Hemo Mill? 1fnot, stale reason Olher chest Worked with asbestos? I I y /; k· / I cCll1lJiliClns Been exposed to Do you have any questions or concents Is parent alhe? I 7 asbestos? (Explain) regarding how you answered the (ff) Ifno, ag.e ill respirator questionnaire? Yes death? I f yes, explain Cause of death Father? Cause of death Mother? h! /1~ .• h. ..p:,?~, Examination Height I~ WeiQht U>\ Pulmonary Function Test Pulse t,fI Blood Pressure IbBh~ FVC FEVI FEVI/FEV Resoiration --Lungs ........ Actual % Heart <--Abdomen " Predicted /4~ % Neck -Nose ---PFT comments ReSDlrator Medical Queslionnaire completed and re";ewed YES NO Chc~1 X-Ray It View X-Ray Film# __ X-Roy Interpretation by: fJf{fldJologst Oil Read"r Asbestos/Smoking Explnnntion: .' , .. -[J "This employee has been advised orthe results oflhis ex::tminalion /' F and has been given an explanalion of medical conditions lhal may /" /' . result from Asbestos exposure, and the increased risk of lung cancer Olher Laboratory Data attributable to the combined effects of smoking and nshc!'los exposure Specific Gravity: f ( C> IOBlood: -Glucose: -Comments Protein: -/' :;> 0./ Vision I 0 Corrected '?fr Uncorrected /?J~/#! / B /101' 3 L 201 1.5 R 20t :s-OUle of exam: l t. ~, Signnlurc of providcr/Pllysicion; ~-- 1).T"4~'n-4.\1,~"'W' ""2U~ .. ,.t...Il''':'''CVI I Respirator Fitness Letter Date: {fJ or-/0 Dear Reader: This letter is to certify that --s;;.o l'S> t \\ S:Q/'l t\y,~ 1\ is, or is not; fit to wear a respirator during performance of daily job duties per OS,HA 1910.134. This decision is after recent completion of a respirator review. 1. The patient is: /Fit_ Unfit to wenr an nir-purii)'ing respirator while performing current job duties. 2. Medical limitations or workplace conditions will include: ________ _ 3. ./ ~ further medical evaluations are required at this time. __ Further medical evaluations are needed at this time, those follow up evaluations are: 4. On ~1~" (date), the patient and the employer were provided Wit a written copy of this recommendation These results will remain confidential, and they will be kept on file In our office. ~ L1C;:~J (Signature OfPhYlCian). Date (printed~~ OccMed Colorado, LLC 550 E Thornton Parkway, Suite 110 Thomton, CO 80229 OccMed Colorado, LLC 3449 Chambers Road, Suite 8 Aurora, CO 80011 ,...""...,.Y"""",I'''¢,tw ..,4lr"'.,."'''.v. .. , ..... QUESTIONNAIRE FOR RESPIRATORY MEDICAL SURVEILLANCE This questionnaire is confidential and will be reviewed by Dr. . If you have any questions regarding this questionnaire you may reach the d-oc-:t-or-a--:-t--:-(3""'O:::3:--) 3=-4""1:--1:-:7::-:9:::9-. ----- Print Namei' Social Security # Birthdate: Age: -s:,(~c:... L\ P., .. '" v\J)) fL 6~6· ?j~.6? 95-(.j(. (I '8'" ?c:: ;$ Employer Job litle Day phone: Height Weight Sex: Male Female Respirator Use Questions 1. if you will be wearing a respirator, check which type of respirator you will use (you can check mo,e than one) ON, R, or P disposable respirator (Filter-mask, non-cartridge type only) OOther type (For example, haif or full face piece type, powered-aid, air-purifying. supplied-air SCBA) 2. Have you worn a respirator before? !l!YES DNa 3. If so, what type was it? __ -If/.L~ct-=Lr.1-:.:-:..-~:-,,-I:~I/,-,,-=-~,,,,-~ _________________ _ 4. Describe your frequency and duration of respirator use? __ ---'k::::O~fJ:....-Lj!.~JU.;!::/.-:!':~4~7L.!.'.,t.'_":~~, _____ _ 5. Describe your work while wearing a respirator? ____ Rl::o!:(<.=-'V'-Ul=·=-··~V..!iA~L=-_P.t!.Jb:tl0Z!,...:_c;r~t7~S<!.· .:.' ___ _ 6. List other protective equipment worn while using a respirator: _______________ _ 7. Describe temperature and humidity conditions when using a respirator: ____________ _ ~. .' d I H' Me ica (story Questions YES NO 1. Do you currently_ smoke tobacco, or have ~ou smoked tobacco in the last month? r -Have you ever had any of the following conditions: / ao Seizures (Fits): ! bo) Diabetes (sugar disease) ( co) Allergic reactions that interfere with breathing I do) Claustrophobia (Fear of closed-in places) ,/ eo) Trouble smelling odors /' 30 Have you ever had any of the following conditions: r ao) Asbestosis r- bo Asthma ,r co Chronic bronchitis r do Emphysema /' eo Pneumonia /' to) Tuberculosis / go) Silicosis I ho) Pneumothorax (collapsed lung) I I.) Lung cancer I jo) Broken ribs I k.) Chest injuries or surgeries /' L.) Other lung problems you are aware of / 40 Do you currently have any of the following symptoms or pUlmonary or lung illness: " ao) Shortness of breath '\ bo) Shortness of breath when walking fast on level ground or walking up a slight hill or I Incline co) Shortness or breath when walking with other people at an ordinary pace on level / ground do) Need to stop for breath when walking at your cwn pace on level ground / e.) Shortness of breath when washing or dressing / f.) Shortness of breath that interferes with job ( _90) Coughing that prodUces phlegm / ho) Coughing that wakes you early in the morning I I.) Coughing_ that occurs mostly when lying down r j.) Coughing up blood in the last month "" ko)Wheezill9 ! L. Wheezing that interferes withyour job / mo) Chest pain when you breathe deepJy_ / no) Any other symptoms you thing might be related to lung_problems '\ 50 Have you ever had any of the following cardiovascular or heart problems / ao Hear attack '\ bo Stroke / co) Angina '\ do) Heart failure / eo) Swelling in your legs or feel (not caused by_walking) \ fo) Heart arrhythmia ( go) High blood pressure I h.) Any other heart problem Y2u're aware of .1 60 Have you ever had an]' of the following cardiovascular or heart symptoms I ao) Frequent pain or tightness in your chest ( b., Pain or tightness in your chest dUring physical activity c. Pain or tightness in your chest that interferes with your job \ d. Heart skippinQ or missing a beat during the last 2 years e.) Heartburn or indigestion that is not related to circulation or heart problems /' f.) Other symptoms that might be related to circulation or heart problems 7. Do you currently take medication for any of the following problems a. Breathifl9_ or lung problems b. Heart P!oblems c. Blood pressure d.) Seizures (fits) ( B. If you've used a respirator, have you ever had any of the foliowinQ problems: a. Eye irritation b. ) Skin allergies or rashes c. Anxiety d, General weakness or fatiQue e.) Any other problem that interferes with your use a respirator: I 9. Might your job duties ever involve 'arc weldinQ or coal handling r. 10. Would you like to talk to the doctor about your answers to questionnaire? I QUESTIONS 11 THROUGH 16 MUST BE ANSWERED BY ALL EMPLOYEES WHO HAVE BEEN SELECTED TO WEAR RESPIRATORS, WHICH HAVE A FULL FACE· PIECE (INCLUDING SCBA'Sj. FOR EMPLOYEES WHO HAVE BEEN SELECTED TO WEAR OTHER TYPES OF RESPIRATORS, ANSWERING QUESTIONS 11-16 IS VOLUNTARY 11. Have you ever lost vision in either eye (temporarily or permanently) , 12. Do you currently have any of the following vision problems a.) Wear contact lenses b.) Wear glasses c.) Color blind d.) Any other eye or vision problems 13. Have you ever had an injury to your ears, including a broken ear drum 14. Do you currentl'L have any of the following_ hearing problems a. Difficulty hearing b. Wear a hearinQ aid \ c.) Any other hearing or ear problem 15. Have you ever had a back injury 16. Do you currently have any of the following musculoskeletal problems a. Weakness in any of your arms, hands, leQs or feet b. Back pain c.) Difficulty fully moving your arms and legs d.) Pain or stiffness when you lean forvoJard or backward at the waist e.) Difficulty fully moving your hear up or down f. Difficul~ fully moving your head side to side g.) Difficulty bending your knees h.) Difficulty squatting to the ground \ I. Difficult'L climbing stairs or a ladder carrying more than 25jJounds \ '.) Other muscle or skeletal problem that interferes with respirator use: Asbestos/Smoking Explanation This employee has been advised of the results of this examination and has been given an explanation of medical conditions that may result form Asbestos exposure, and the increased risk of lung cancer attributable to the combined effects of smoking and asbestos exposure. (In accordance to 29 CFR 1910, 134) Comments Dale of exam // ((J ~/ ". ..... ~J Physician Sig\J~tur0· GOBBELL HAYS PARTNERS, INC. 10590 East 54th Avenue, Suite J .:. Denver, CO 80239 Ph. (303) 574-0082 .:. Fax (303) 574-0061 CERTIFIES THAT JORGE HERNANDEZ Has successfully completed The 40 hour EPA-APPROVED AHERA ASBESTOS COURSE for Contractor/Supervisor and has passed the required examination in that discipline. This course is EPA-approved under Section 206 of the Toxic Substances Control Act (TSCA) and meets the requirements of Colorado Regulation No.8. Gobbell Hays Partners, Inc. purchased MCA Environmental, Inc. and course approval can be found in the EPA directory under MCA Environmental, Inc. listed as training provider #931. 12/14109-12/18/09 12/18/09 Certificate No.: 12/09CSGHP2 Expiration Date: 12/18/10 • • bovman DATE 10/18/10 TIME 10:32 BTPS 1.097 Ver 3.4 NAME Hernandez BIRTH DATE 06/08//2 AGE 38 HEIGHT in 67 PREDICTED Knudson PRE FILE N° 88 Jorge HID 056886995 SEX'; yJEIGHT Ib 201 PRfD. CONVERS ION 100% FLOY·j-VOLUME & VOLU/~E -Tl ME cu rves (+) FLOW (l/s) TIME (s) FVC L FEV1 L FEV1% % PEF l/s FEF2575 l/s FEF25% l/s FEF50% l/s FEF75% l/s FEV6 L FEV1/FEV6 % FEY s VEXT rnL FiVe L FIV1 L FIV1% % PIF l/s 5.09 4.48 88.0 7.64 6.50 7.50 6.73 2.98 5.09 88.0 4.11 110 4.43 3.68 82.7 8.66 .3.95 8.01 4.70 1.91 4.43 3.68 82.7 8.66 %PRI'.D1CTED 115 122 106 88 165 94 143 156 -. -...... -. ... SP I ROMETRY lNTERPRETAT ION No rrna I Sp i rome t r\l .' ·,'" / , / , , . • / / ~.-.;' -' " J " . • .. ; .. c • ... • . . En1)ir-onm~t4ISafety,.~nc. '" • .. 'C<","" Awarcl'S<to" . .' ... , . '" . :.~ .. ' . 'I~iites tliller ,... .' .. : ,,_:~:.;:"c:".::: .. :.~.,. ..... :~: This:' ~, .... c.:~ . .." ... : ...•. C_ .•. : ... ~.~.c: ... :." .. ' . ',' . c .... ,. .. .. c .. , ". Ceffi.fi~~teofA~hieveirient.· ".< .. , ~ '.: .. :.:.'.: ... ...::.:.:.~~~:f; .. : ... :.-. .... ~;: .. ' , . ". :,' . '.: . . ." .....: .:.: ...... , .. ' ···-co . In 't' ,.' ., '. . ••... "'~ :.:: • J • : ,. ;.··'8.~f.{Qijr,AI:t~RAi~~~~tQS 's:upervi$loJ; RefteJherCourse···· ", ' ... ·/tNsc~;is,e i~EI>i<lpprg~¢'4;kd.~r TSCA. Titl~,n&; Celorado AQCCR~gulatiohN o. 8' .' ; .. ~; ," , . '. . .; ',.: .. ;.-',: ,~::"'':: ,~:.;" . ": . ' . , ' " . " . -,.' ". ' . ''';.. ", '.. ·:'\·i:':~"·,.',".·":'·/"·:' :". . ,'. ,'.' " .. ::: . ." , . " ' .. . ' . "' ,,'., .. " ' .... ',' l' ~, .... ',', ;;:.:.:.:!:--.: ..... ,( :';'" :' ';" '.' .... ,,;' '. . ........ . . ApJ;ill0;2bl0.:.~.'" ..... ,: .' .,' Cours.e·<:6mp1efecF:'::":>;·; .' . :, .. . . MaJ:kH~rnandez/4654' In'struct' or"Stare'ID',#:. . .... . I.. " ::',~/':' .' :. ' .... ; A~rora;C(l 80046-0246 . Phone: 303--340-431.5 Il:t/VV/J .'. 10~324" , ;'ID# .' ,.' .. ( ·6,1$ FROIr'rWiC£IfTRA SOUTH Conwntra Medical Centers 1z\i!81S~8W1tiO ~"ICQ C!0210 p...,... (WI m..,n ".,.. _ 011""'" PLHCp1 WRiTlEN STATEMENT for RESPIRATORS (l'iMf'J..OYI;E) iimploY61l seN, 5z4-04-63Bl 't DENVER: ~~·:~;r~:g: '~.~_ i:?i!: • CC: 60227 . '. "', -t .,..~. .' "",ploy",: S&G'!!i\\iirp,mnental . You w,~re ~vaillal~d In thl" office ~f yolir'n>"5!lclIl .. tatu .. Nllale<i tQ your pnys'o,,' cap~billty !<> wwr a rospITilr"";·(Ch&rlk'/ 2!W tnllt apPlfe~) ~'ll''' were no aooormlli find~s mat WOIJId'~empGr':YOU' abUIty to perfonn your fOb dutiOS willie wearfng a '''''plrator. ( OTh<t @bnoirnaJilndings I"ted bolOW 'NelS not ",Iatad l6wearing a r""plrator but ohould be reported to your pardonSI physician for further evei1U611lOn. • fo2~ d upon the r .. ~u"" of ttlls ftVIlII.l<tt!ol!'lt Is MY opirllon ttJ.t you: (Cll~k if AJ.l.. tfllitapplY) Uii qualified to wear a reaplrator. o H',~ lhe followlnQ res1tict1on. concerning respirator USage: __ ------------- , 0 AHE NOT Quallflad 10 we .... a reaplratot. o Rcquir& further tllllflog by YQur prlvalG phyaiclan who must submit a written report of hltiher findings to C'>nGentl'l!llW<1dICIIII C<lntors so tlutt annal <lectsloO OIl yow Il/lUIty to W98( a "'.pllator can bl!> mad~. L.. Must wear SP~!II ~lpflOO eye-weftr n~ 10 aceommodB!e respirator. o Must use fln EYf$ glettiS convemion kit. o M/iy need to shave Fae!~1 h,,'r to assure tigl'lt 50<11 on certain hlcoo masks. o NbSd 10 >top "'nol<i~g. c iEk7 AJ.J. thaI appbdl ~ ibw$ iJWloJkll4ll.tl.!.S.I*fI ~ 1or~1ot ClDfi$;" ~wkh 20 CFR 1Q1D.1~. TtW IJMod ev~luadoil iii apOe!t1eto t'Oi(JflJ'1Of \J'<\9O!'1Iy.~~F~bq;tr.wln.dadtAfCPCHlOhztJllr~JrJW;:fQ~DI~ofW1y~mMll)tholr~«~n.. ir\'(\lf>Iok,I.)fJon~ UlaRtopltRUK)'~reOVl,;.,;f k1 ZI em 'Cl1'" 1;14. o T ..... """" ""Mi,,'J:!MlItIJ' """n_.,. ... tor""'""""'r.w....lho~_J<"J~_"' • ......,,,OIOl!Hi\·.MoQw'''''''''''1lOO ~UINI/Onrudnt 1ft AppGn~ c;: p"d A ~ 2. k\ ~~.,.;tn Pb c(ltt 1010. lMt m!~ ~>td ~.J{Il!OtI i$ ~ Ir1 ~ ~~. e~ Ul1r:nM at inIfMlI+d "·l'<'>rt"'1_A""' • ...,g~or_"'''''pI1~ .... '"' ........ '''_ ... _. Tl'j._IIon_tfIo""", .. """a.-lIon""kw r.-.2~JIoIld Ili2SCFR 191D.l~.· . 'l.}:.Pri'ro:xtfa(lCQ WlIll ftJl'J.Ciwr. t;)8tiA 1'Ifq4l~".1 00Y!1 inf0rmi4 U)(jI Qbovo niUled 1~)dtr81 Q, me ro»ul\Jf!'.lt ttis ~ aMot 00i ~ t;MditiOO6 f'}"iUflioo rmnt / eJ(~.1t1OI flWICl4ullt l'UtitIoc .OOb'JOI~ Wn+r6~.lhQabo-,owfllmld ~~ ~b!JtnfrrfonTled ""1f',e~ ri.k of IuOU CIhOIt '!~bo1eot(f to: inti ~ta tlft(:l« ~ iInD',~ I<Ud 1fndoIQr!Met cllomrt.l ~~'J. MJp.W~rnuu"~~'*'a"""~"'AJM«Itf»I~.sWIi~~htvPl/lJO~h~~WilM~At.J~fgftHpwtMU~M"Ii~~~i:ln .atKI~ f;;t, ~9f*'J.<IIq9MtMItMI..., tIM~9f~ ~~ tI) IO"Ht ~1mp1r.l"'" ~ Ilf tIrtrH It'~_ J;ilTf INJ'M fIM~~ IIffilalMneJ:J .I'1~thwtM~Dl~ w..a.wl11<.<dh"~IP""fJ#a#IB'_~~tN~.&htt16~'hnltPr1lanJ p.~.,.~"",~~glil, J~ ~ns. PLHCp Name (printed) '~,,,,td.n 1lf0ll\e< l""""'" """'''''"' P_I / To bv mQllltAl~ In th •• mpIOYI)Q'& 1Ua wttft, ~gPY to rho ttmpJoyu Pogeloll ... Print D;olu; 0711312006 ~yt~on Oa~; ~/06I2000 ., £;OO'd 'lVW.L Ii! ! ,I .' I • l ;. I ~ j:i ! . Iii i '. ; . I I I PHYSICIAN'S WRJTl'EN OP~NION -A~BESTOS :: : ~ I! ! . , > , , ' Applicant's Name: -MMIO """J"l;.l'l..~ ONES i:; Address: 13~OO A~1ff'Bf\' Oe~Ufl>..c.(I, ~()~"tlij Th~ above nam~d was seen by me on 6~' V-(/'c;. , pod i" ~ccordnncc "~th nil applicable ponions of OS! fA's Asb~stos Standard for thc ConstnJclion'lnduslry. 29 CFR ! 9:26,110 I. with whi~h ~ am fumili~r.1 have incicated by my initials, that 1 hav~ ",rformed the following, ill ; I:i , I. ~ Reviewed wilh Ihls inuividual, hiSlner completed OSHA sl.nd~idi~ed Medicdl Questionnaire and /' Work History, directed towards th~ pulmonary, cardiovascular~~nd gastroint~tinal, system; and ~ . R" hi' d " f h' ' d"d I' d • Iii hi' \ L.. h ~,___ eVI~W¢" t e emp oyer s escflpllon 0 I IS," "I ua S unes as t ey rc ~Ic 10 a~",,:slos exposure. t c anlidpated exposure level. the person. I protectil'e und resplralOry cquipmendo be utilized by the / individual: und any additional m~dical infonnution resultin~ fr~m previous "x,bminalions; and ../1 t 3, __ Conducted u physical examination Qflhis indh'idual wltl! emp~~ils;on the pul~onary. c3{diovas~ular, . and gastrointestinal systems. including a pvlmonary function t~) of forced vitiJl capacity (rVC) and ~orced .e~riratory volume at one second (FEV-I) and :' ~ : ; 4. _ De(~rmined that a chest rO<!ntSC1'logr:lm was _ was not L--:J4uired as a pat\! ofthi~ examination, (If / tequired. Ihe x-ray was taken and read in acc_~rdance wilh AP~ldiX E oflhl; tSbestos Standard): and S. __ Detennincd that this individual may ""'-;;;;y not ~ use a re~iratO!)' de\'icelwhil<:: performing his-'her / required employment services: and " II : I 6, __ lnfonned this indh'idualtnat I hn"e .-:... htwc not ~~cted ~iml:llic~1 eond\tion "hieh \\'ould place -...-/ this indi\'idu~1 at an increased risk ormater;'1 h~alth impairment from exposure to asbcitos; and / I:! . j 7. 7' Informed this individual of the results of my examination and 9iriany medicslbondition that mny result from this Individual's el(posur~ to nsb~stos: and I ; l , , . 8. _ [nfomled Ihls indi\'idual of the healih risks involved in Sri10kin~.lof:th~ syner~stic relntionship between cigarette smokitlg ~nd asb\lstos txposure in proJucing!llung cunc~r, nod Ihllt emotion of smoking ",ill reduce the risk oflung cancer, j. i '! .. I \ I" , Comments and/or LimitQtion~ (if nny): ;: ! :! : , I ]fp£ R~ht4cber U.D, (Physician's Printed Name) (Physician's Phone No.) ! £00'<1 "I !i , , IP (Physician's SigQature) I: ; Occ~d ,Colorado, iLLC 3449 N. Chambers\Rd., StG. B Aurora. CO 80011\ Ph: &20.S59-6139.fax: 720-e59·S294 (Physician's Adl:lress) . i -, , , . ; 99: 60 010Z'-vO-Nnr , J GORBELL HAYS PARTNERS, INC. 1{1500 East 54th Avenue, Suite J <-Denver, CO 80239 Ph. (303) 574-0082 <. Fax (303) 574-0061 CERTIFJES THAT MICAH A. NICHOLS Has successfully completed The 40 hour EPA-APPROVED ARERA ASBESTOS COURSE for Contractor/Supervisor and has passed the required. examination in that discipline. This course is EPA-approved under Section 206 of the Toxic Substances Control Act (TSCA) and. meets the requirements of Colorado Regulation No.8. Gobbell Hays Partner.s, Inc. purchased MCA Environmental, Inc. and course approval can be found in the EPA directory under MCA Environmental, Inc. listed as training provider #931. Course Date: 6121/10-6125/10 6125110 6110CSGHP2 6f25!1l Exam Date: Certificate No.: Expiration Date: GOBBELL HA YSP ARTNERS, INC ....... . . . . 10500 East54th Avenue, Suite J .:. Denver, CO 80239 Ph. (303) 574-0082 .:. Fax (303) 574-0061 I CERTIFIES THAT MICAH A. NICHOLS .. Has successfully completed The 40 hour EPA-APPROVED AHERA ASBESTOS COURSE for Contractor/Supervisor and has passed the required examination in that d~scipline. This course is EPA-approved under Section 206. of the Toxic Substances Control Act CTSCA) and meets the requirements of Colorado Regulation No.8. Gobbell Hays Pm1:ners, Inc. purchased MCA Enviromnental, Inc. and course approval can be found in the EPA directory under MCA Environmental, Inc. listed as training provider #931. Course Date: 6/2111 0-6/2511 0 Exam Date: 6/2511 0 Certificate No.: 6(lOCSGHP2 Expiration Date: 6/25/11 ( Health ~:'I W o.ccupational Medicine and Rehabilitation • ._. ___ ._ o' _, ••••• -,. ,", ' ••• ,", "' -_. n~hr·H .. , ! }ut~~ OCCUPATIONAL MEDICINE 120 BRYANT ST. [l)EIWER, CO 80219 ASBESTOS OSHA 29 CFR 1910.100]/29 CFR 1926.58 MEDICAL EVALUATION, PHYSICIAN WRITTEN OPINION Dat/X B ·tD ·/0 , Employer)( AfliNE Oo'V\ol.'t,or-.i Employee NamejC_" _!...-M~; Ck~t:..:......cA~·--,-tJ-"-,-i,,,,"c1.:.::o,,-,-,(s,---_______ ~ __ '.." Initial Examination;;@ , .. , Annual/Follow u;T; Medical Questionnaire completed for initial exam ( ) Abbreviated Questionnaire completed fot' annual/follow up ( ) Chest X-Ray ()1"YES PFY WNL () YES ( )NO ( )NO I have according to Federal Standard 29 CPR 1910.1001 and/or 29 CPR 1926.58 physically examined and reviewed the medical data of the above named employee. l~hiS employee can wear a NIOSH/MSHA approved negative or positive pressure respirator without (N! ;roduCing cardiopulmonary stress dangerous to hislher health. () This employee cannot wear a NIOSHIMSHA approved negative or positive pressure respirator without .",p producing cardiopulmonary stress that may endanger the health of this employee. \ A The employee has lIO evidence of asbestos related disease. () The employee has evidence of asbestos related disease. THE EMPLOYEE HAS BEEN ADVISED OF THE RESULTS OF THE EVALUATION AND HAS BEEN GIVEN AN EXPLANATION OF MEDICAL CONDITIONS THAT MAY RESULT FROM ASBESTOS EXPOSURE, AND OF THE INCREASED RISK OF LUNG CANCERAITRIBUTABLE TO THE COMBINE! EFFECT OF SMOKING AND ASBESTOS EXPOSURE. EXAMJNERS~ DATE Asbestos Medical Em/l/miOiI/OpInion OHS!917 (6/971 ( ( \ Course Title: Course Date: Name: 10500 East 54th Avenue, Suite J Denver, Colomdo 80239 Phone~ 303.574.0082 Fax~ j(j3.514.0061 GOBBELL HAYS PARTNERS, INC .. 010 ado Cou 'se E rolIment.Form 5 a.t V VI~O r Employer: ----'.L(lJ=[,-/",P=LftL;.:.=-D==1 C\,.-'efll1~() 1L=·cwb--=OVl_·'---___________ _ Contact if student is unavailable: _13~e2:t':!"'tv'4,I'--LJI/lJ=e-"-'d:.J.-V!.=:....L/--__ -------''1JjJ'_''ni::.--=?.;;t8=_1=/--Ll.--<-'JD_f-l-_ E-mail address: wlil @ ¥ Z;;t ~m (J Iiii iv! . til \til Phone Number I '-'-'f Work Cell Phone: ?;O~-Lf-7--f"-?2oW Fax: 7(),8-1to-Oflfefj Phone: 1Z1J~ ~86-0/~5 Work Address: 6710 ilL "/) (if I\.. fJI,tf -If C. iW_ /i) 8 trJ) 2- Street City §taTe Zip Code Home Address: 31.eO::;' bCL-tl511 S-t. iUhtttkith6 (0 80212- Street ~f.",/\ Q lJ PAYMENT (TUITION) AMOUNT: ----lI1:L~_'__ __ PAYMENT METHOD: Check: ~Xw"r----- City J Visa/MasterCard Number: _____________ _ Name as it Appears on Credit Card: __________ _ . State Zip Code Exprration: _________ ___ Signature: ________ _ • Note: Payment for all classes must be made on or before the day of class by check or credit card. A cancellation fee of 25% of the tuition cost will be charged if student does not cancel at least 24 hours prior to the start of class. • For all asbestos refresher courses, student has 1 year from the date of the certificate expiration to be eligible for a refresher course. Student is responsible for determining eligibility. Please submit/fax a copy of your Iilost cutrent refresher certificate when enrolling in a refresher course. • The Asbestos Inspector Refresher and AMS Refresher courses are from 8 a.m. to 12 p.m. The Management Planner . Refresher Course is from 1 p.m. to 4:30 p.m. All other courses are fi-om 8 a.m. to 4:30 p.m. Jfyou need any additional information, please call Laura at (303) 574-0082 or e-maillmccauley@ghp1.com. • In the event of course cancellation by Gobbell Hays Partners, Inc., tuition/fees will be fully refunded. • Students not accepted to the school are entitled to all monies paid. Students who cancel tllis contract by notifYing the school within three (3) business days are entitled to a full refund of monies paid. , GHP is located one mile North ofI-70 on Havana St., ill the Stapleton Center. The Address is 10500 East 54th Ave., Suite J, Denver, CO 80239. Havana St. is a north -south street with 1-70 access located between the 1-225 and 1-270 intersections. • Approved and regulated by the Private Occupational School Board, Colorado Department of Higher Education. (!HP Course Enrollment Form Pagel By signing below, the student agrees to pay Gobbell Hays Partoers, Inc., hereafter refelTed to as the school, the total stated tuition & fees. The school agrees to provide the occupational training in accordance with the provisions of the 2008 Catalog. Payment of all monies due shall be a condition of continuing enrollment. Upon satisfactory completion of all academic and skill requirements and when all financial obligations to the school have been met the school will award the certificate to the student. The student and school ( lderstaiid thiifthis Enr6llirieritAgreemeiit;wmCHlNCLUDES:TIIKREFUNlXPOJ:;ICYmaynot:beameuoed el\~ept.ilr;vriting and signed by both parties, . Postponement of starting date, whether at the request of the school or the student, requires a written agreement signed by the student and the school. The agreement must set forth: a.) Whether the postponement is for the convenience of the school or student, and; b.). A deadline for the new start date, beyond which the start date will not be postponed. If the course is not commenced, or the student fails to attend by the new start date setforth in the agreement, the student will be entitled to an appropriate refund of prepaid tuition and fees within 30 days ofthe deadline ofthe new stmt date set forth in the agreement, determined in accordance with the school's refund policy and all·applicable laws and rules concerning the Private Occupational Education Act of1981. Refund Policy Students not accepted to the school are entitled to all monies paid. Students who cancel this contract by notifYing the school within three (3) business days are entitled to a full refund of all tuition and fees paid. Students who withdraw after three (3) business days, but before commencement of classes, are entitled to a full refund of all tuition and fees paid except the maximum cancellation cbarge of$150.00 or 25% of the contract price, whicbeveris less. Tn tbe case of students withdrawing after commencement of classes; the school will retain a cancellation charge plus a percentage of tuition and fees, which is based on the percentage of contact hours on the last date of recorded attendance. Refund Table .1 "tudent is entitled to npon withdrawal/termination Refund .ithin first 10% of program 90% less cancellation charge After 10% but within first 25% of program 75% less cancellation charge After 25% bnt within first 50% of program 50% less cancellation cbarge After 50% but within first 75% of program 25% less cancellation charge After 75% (if paid in full, cancellation charge is not applicable) NO Refund· 1. The student may cancel this contract at any time prior to midnight of the third business day after signing this contract. 2. All refunds will be made within 30 days from tbe date of termination. The official date oftermination or withdrawal of a student shall be detennined in the following manner: a, The date on wbich the school receives notice ofthe student's intention to discontinue the training program; or b. The date on which the student violates published school policy, which provides for termination. c. Should a student fail to return from an excused leave of absence, the effective date oftermination for a student on an extended leave of absence or a leave of absence is the earlier ofthe date the school determines the student is not returning or the day following the expected return date. 3. The student will receive a full refund of tuition and fess paid ifthe school discontinues a course/program within a period of time a student could have reasonably completed it, except that this provision shall not apply in the event the school ceases operation. 4. Complaints, which cannot be resolved by direct negotiation between the student and tbe school, may be filed online with the Division of Private Occupational Scbools of the Colorado Department of Higher Education at IVIVW .hi~hered.colorado.gov/dpos, or at (303) 866-2723 There is a two-year limitation on the Division taking action on student complaints. 5. The policy for granting credit for previous training shall not inapact the refund policy. ryt:, 0 IDS ENROLLMENT AGREEMENT AND A CURRENT SCHOOL CATALOG. 6·iO·/D Date School's Ucensed Agent Date GHP Course Enrollment Form Page 2 ( H, Occupationalll1edicine and Rehabilitation fName: M'-oJ If· Respirator Fitness Evaluation ,~,,~.-' -.-"-" Employer: __ '~4!-!I+-e:..:..-;~=-· .~:...~ •..• _':-l()~.E1M::.:' .'.-:". -'~ l,-,-"'-,--~:.='~~N'--,' .'._ .... _. ________ _ -I _._Immed. Dangerous _Incr. Temperature _Oxygen-deficient _Increased humidity _Oili~ __________________________________________________ __ Respirator type: Cartridge type: __________ _ Check all that apply: _ry.nf-face air purifying ~ull-face air purifying _Low-pressure air supplying/purifying SCBA _Organic _Dust _Other: ____________________________________________ _ Hours used per day Work conditions, ____________ _ or per month __ Exertionlevel, __________________ _ Other exposures: ___________ ~ ______________________ _ Prior respirator use: __ Yes ~ In military service? __ _ Any problems?: ____________________________ _ (fit, leakage, dyspnea, etc.) Familiar with respirator use and maintenance?_.--: _______________ _ ~!£~W\<oS 'ctions in respirator usage. pirator usage approved with the following restrictions: Clement J. Hanson no _______________ ~=_t.....!t'\-t--f:(Y;tleenset! ~4/J.r\? rp-q U ~"CJ _No respirator usage approved due to ______________________ _ Physician Signature Respirator Fitness El!afuation OHS!911 (6J97) -. .~ Occupational Medicine . T and Rehabilitation Spirometry . . a e: Name M"~ if· tJL~{~ Company 11(-.,-.-~.~ '1l' .. .. --0-,. -.' S j .. : '--::~-. -.'-... --. ''/! .. t'NCf)e-Mo(, .' oA/ ._-,," Daleof Birth •. ··Age Temperature Sex~ Height: Social Security No. t '8',1(, JL{ M C 'OH F 2.'16 '31 . .s--g J ~ L- Actual Value Predicted Value % of Predicted Value . .. .FVC; liters s. Z-'3 lite rs FEVj , :5 liters l' FEVjiFVC % 75% RESPIRATOR CL~ARANCE GUIDELINES / m I·J.1~1.'1'.I.'I·.I.·I" tltl~I;JU' • ·I,J',w·.,:'l'.I:!'.': •••••• :~t'·till:· /·::f·P· .. · • RE~OTNE '. J • ·l"! .... .o. 90 ..... r.· ~t~!!J;;' .. :-. MO' • kn:...e· ': .. :' ::. · . ·.1· .. ....""'1(l.Il4 "" ' •• · ...... . . . . ~ . " .. . ~ . •• ". 11 •• ' ••••••• • • • i • • • • ••••••• jAooor."'''1 .... •• • • • • • .. ::::~ ""~I\VYOJ 50 ( ••••••••• I •••••• " •••• , •• .................. , .... ~ ...... "" ..... ,o.::. . . . . ... . COMBINED .. ": .. -::::: ... '$, :::.~:::.~ JJU!.ll ., ... .. ' .:::;:::::::::::.y: . ... . '. . ......... . . .. ... . . .. ..... . . " " -... . .. . . NON·APPROVED . ... " '.: " .:: .. :.' ': : : :' : I:J: :.j.: :·111 r ~ ; • • '.:', ,! I "" ... • ~'~.: ~.~ f..Jr..1 • ' • I •• t I, I. , .. ,..,,,,,, •. ,JE . '" . . . . • I •• 0 • • I,' ' ••• "' to .L''''. ".1 '00 • " •• • 0 • 0 • • I • • • I ,.... .. • • to ., .' ... ,. " ....... ,.. " • .' " " '. " " • I .:',. • •• • • BCYl:RE · ..... . ... .... .. • 0 '\ •• •• ,..... •• t. ., •• •• • ., •• .... .. .. .. " .. . . t ...... ~ •••• 08Sll1ltC1l\"E . . '".,. ," . • •• '0' ,. o. o. • " .,. •• "I, " I. •• ,.,'. II' ., ., " • " • ,. " II, I, • • .:'.:' ... :' • .' '.. • \oBiy'SEVi:RE". • .: ... " ..... .".. ·l-t';I·I·I.'WI~t·. J:) 20 00 40 W' , 'eb' "70' 80 00 m 0 fVC \I OF ffi!:OO lED ~proved o Not Approved J ",anson tltl ~\ '. ~ ?>M{\1 --~L::..fF.-::=-::::-:::-=-__ --,-,,-_---1 DID DATE ATTENDING PHYSICIAN / PROVIDER OHS/912 10100 ( From +1.303.446.3230 MOil 16 Aug 2010 02:46:56 PM MDT Page 1 of 1 HealthOne Occupational Medicine at Bryant 120 Bryant Street Denver, CO 80219 Patient: Nichols, Micah Date: August 10, 201b 14:57 " o~~~e)8:-. -' .. ~~,-.june'15,-1976 ~ID No: M061516N" . . """,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,'''''',,,,''''''' .. ',,,''''''w,,''''''''''',,,,,,,,,,,""""""'"''''''''''''''''''''''''''''''''-'''''''''''''''''''''''''''''""""",,,,,,_ Examination: CR PACXR Referred By: Halat, NP, Deana Exam: Chest radiograph, frontal view Date: August 10, 2010 History: Physical exam. Comparison: None. Technique: Frontal view was obtained of the chest. Findings: Lungs are clear. Heart and mediastinum are unremarkable. No pneumothorax seen. No pleural effusion or pulmonary edema identified. Osseous structures appear unremarkable. Impression: Unremarkable frontal view of the chest. Slot 15 Electronically signed by: Eric Handley, M.D. HealthOne Occupational Medi~MJ1t ~r~nt711f!1llJ<>rt exported on Man, Aug 16, 2010 14:43:13,0600, 1'age 1 of 1 ~ ~ p ~ 1,1M;;; bl ~_ '.J ,_. . r .( Asb17stosJResplr'ltor Physical Form" ~a:n.t: M I c.A Ii iii Ai /1:.+/,0,-" S SocialSectirilyY, z'1o. )'? j1l3$" Work YiSll II: f} r:vvwl; ~. D N City: I/rvltJIf \ fllacc ofJJlrtll; CM'Ef{ S p<,,"-<> , \ PI,"" cLeck Ihe appropriate box Complete ii, n, Cas noteq , I .~lb<sIOs ~~I)'slcal s:(:;omplcte AJl,C Res?i1fl!Or Physical f:(:Complcte A,B ,\. )ltdic3;[ Hi.~tOry Sllpp!,-m~nt 10 R.espirator Que.stionnair<:-1910J34(t)(2){I): \ Prescnt Ocoupntlnu: !d On?r- State: Co Dale: 'O'/6'/Q fIjghCst grade completed in SCh,lOl'l /2.. g Yrs Zip Code Re."pJrotor Ml;dical QuCSliQJln~ire completed and I1wfewed D ! ! \ : , I C;uct:ic b[ur.chiti.~? l=r.~rh!5~ma~ A::;hmfJ? llfle~;I'l;;:l::<t (.H;; ~hw (omJitions1 h pl!tr.t tJIT¢utly nlivc:? ~f r,o, ,l5~ i:.1 tlei'.th? :'IJ~,:'Ir:; C>l\!$C of death? ·F~~h~r. \1\ C. .. \sb~sto~ History: i )):1 YilU ~utfVi'[ly orha\'e you in Ute past worked in Iheseind\ls.tt:es? ; Yes: NoNA Yrs ! i!\'tl. iJdi'3Ic YMrs from·To: Example (1995·200.0) ! W({"i-:t.1lf1 1 Mmc:? 0 W..o , l \YL'!"].:cd i:-. Foundry? 0 t:f 0 ~ W~;k~.1 whh Pillttfy1 [) g/(J _________ \ WQ;'~e1jnC(lllonorFI!'.:dl'nlpMiU7 0 W"'p _~ __ \ Wv:-hd wi,h Asbcsl(Is? 0 !0'" [J/ _____ ~ \ lhH: \Ull creroccn eXPQsI;d 10 A~hcsto~7 Q 0 '0 ___ _ '''1' -'" j. r..xp 1m. :! t.::;----~-~----.~ ----- Other r'-(Iooratory Datu: --'-~---------'--- A<lhts{o~!SmokingnxpJaJ)!ltlOJJ: ( cO: h· ..... ;u .. 11\;1 ~' ... OCCUPAtiONAl. MEDlt)INF. .. 1211 BRYANT fH. llittlllER. CO 80?'l!) ;umrSTOS OSHA 29 eFR 1910.1001/19 CFR 1926.58 MEDICAl. BV ALlJATION, PlIYSICIAN WRlT'l'EN OPINION DW)\_ B '(0 'ID~ Em~lO):er:x-fH/il'it j)E""Mol.·+:O~ Initial ExatninulionJ;(7 AIUlllalfFoHow u~T; tvt i wYL A-tJ; c1., {s ).icdicai QUestiOllllairc completed for initial exam ( ) .'.bbT(vi,tled Questionnaire con1pletcd for arumal/follow up ( ) Chost X-Ray cltYES WI W).lL () YES ()NO ( )NO I hJ\'e according to federal Standard 29 CFR 1910.1001 and/or 2.9 CFR 1926.58 physically examined and re\'icwed the medical da.ta ot the above named employee. ! ( ) This <;mploye<> eM wenr n NIOSI-lIMSHA approved negative or positive pressure rc~pirotor WitllOut producing, eardiopulm.ol1ary stress dangerou~ to hislhcr health. This employee cannot weI.r a NIOSH/MSHA approved negativc or positive pressure respirator without producing cardiopulmonary stress that may eudanger the health ofthis employee. The employee has no evidence. of asbestos reJated discaso. The employee has evidence of asbestoH related disease. n if. E~!I'LOYEE HAS BEEN ADVISED OF THE RESULTS OF THB EVALUATION AND HAS BEEN (i]VY:N :XN EXPLANATION OF MEDICAL CONDlTIONS THAT MAY RESULT FROM ASBESTOS t::\l'OSuRE. AND OF THE INCREASED RlSK. OF LUNG CANCER ATTRlBUTi\J3LE TO' THE COMB1:--l',( EfFECT OF <:!MOKlNC AND ASBESTOS EXPOSURE. £XA:vnNERS 31 bATE AsbesuJ$' Medical E'~'(]hrli!fI'IJiVj,,'r,i,k OH.WlI Ui.·fr; ( ~OceupalionaJ Mediclue ....,. and Hcb4bllit,tioll Respirator FitnesiEyaluufillll Nam~;fV1 ; wyC il; . N ; dw If -----~~~--~~----~-------------------- EmpIOyer;_~4'-.:I,+l_; .v~'"_l<.f)-",-E1N:-o...l ".:...( I:....>' {-'-'·;"::..cN.::...... __________ ~ _lmmed. Dangerous _Incr. Temperature _ Oxygen-detlcient _Increased humidity I_Other Respirnlortypc; _________ Carttidge typO! _________ _ Check all that apply; _lj;Jf-face air pudfying I ....lJ'ull.face air pmif-ying _Low-pressure air supplying/purifying , _SellA IiI __ Organic 't. _Dust I _Other; I Hours used per day FfSMs-. Work condltions. _____ ~ __ ~ __ I or per month _ Ex.ertion level _______ ~ ___ _ Other cxposures! __ _ Prior respirator use:_ Yes ~ In military service? __ Any pr()blems?-:::~--::-_-:--__ ~:--_________________ _ (fit, leakage, dyspnea, etc.) I Familiar with respirator usc and rnaintenancc? _______________ _ L ~~~'i'i.·U·ONS: -spirator usage approved with lhe following restrictions! I i '\ 1'.( sttrt'tions in respirator usage. ~ L.~ . "lem0nt J. Hansol l/-' --------~~-------" .~~-'------__ __\:_1.i 4'''' -----'-"!'Y:t\cel"s~ll~ ,,,.' _No respirator usage approved due to r-~ C ----hO Pc .L\ Physicirul Signature Respirator Flrneis t:~'r11/lnfian OW!J9JiIW97) .~-------.~ ,I?r OccupntlQual Medicine _ and Rehabilitation " /' .. "--' ':,,-, - v ;vI'<-.4-4· , is· IDaie of Birth Age Temperature t J~'16 J'i 1-. Actual Value . .Flfe liters FI;:Vj Iit~rs FEVj/FVC % Spirometry Company Sex~ Height: M-&'0" F~ , V_8 i O la. I bate: flljJl'tJE' I'k;YV1.0 (~-b'o.v Social Security No, 2.."'/6 • 31 .. S-S' 3 S' Predicted Va.lue '% of Predicted Value ;: 2-'3 liters • '3 liters :3 75% RESPIRATOR CLEARANCE GUIDELINES 'PO L J -" Jt~'t'I"I"I: it I':';~~'~ -l-IOflWJ..l 00 t::W:::: , :!:! v~ Iffl'l1OVEQl so :,'::. V -.70 ... ~. :.;. '.:,'.'.' ::.' :.'.',', :[::;'i!.t::, ~ 60 :::.'ili::~~::::::::::':\ :.... .. .... :.~:.:!:J 50 40 '00 1:1 )P. , 20 :'c ;~~ tl \. :,: , .~ 's 11;,' 0 '1;)' If 10 ~proved G No! Approvod DATE AITENDING PHYSICIAN { PROVIDER OHS/912 10/00 ...................... ...."...., ................. , ( From +1.303.446.32.10 MOh 16 Aug 201002:46:56 PM MDT P~g. 1 of 1 HealthOne Occupa.tional Medicine al Bryant 1 zoBryantStreet Denver, CO 80219 Patient: Nichols, Micah Date: August 10, 201 b 14:57 DOB: June 15,1976 ID No: M061576N .w .... ,.,"",,, •••••• • .. ,,,,..,. ... ,, ••• ,,,, ••••••••• ,,, ................ "",.","',""" •• ·n.' .... ""'"',.·· .. " ....... ""'"',._.", ........... "", ..... ,,, ...... ',, .. ·,,,\ ..... ,,,,,""" .... ,, .................... , ..... ,,,,,.,,,"',,,,,,, ... ,,,,,,.,.,, •. ,,,," .......... " •.• Examination: CR PACXR Referred By; Halat. NP. Deana Exam: Chest radiograph, frontal view Date: August 10, 2010 History: Physical exam. Comparison: None. Technique: Frontal view was obtained of the c;hest. Findings: LUngs are clear. Heart and mediastinum are unremarkable. No pneumothorax seen. No pleural effusion or pulmonary edema identified. Osseous structures appear unremarkable. Impression: Unremarl<able frontal view of the chest. Slot 15 Electronioaily signed by: Eric Handley, M.D . ...... "-..,. .... .. ~ ......... -~.--. ~---. -----.,...... HealihOnt'J Occup~t!onal Medi&i-M:at Sry~nt ::8fJport ~xporltd en Mon. Aug 16. 2010 14:43:13 -0800· Pose 1 of I ~~G,~I""/;I:J ( Health M':T Occttp3tio~~1 ~edidne -,--. an.d Rehabthtahon rlt.hL.; '. il~:~ OCCUPATIONAL MEDiCINE 120 BRYANT Sl~··· IDE~R,CO S021S ASRESru.s OSHA 29 eFT{ 1910.1001129 CJ<'R 1926.58 MIWICAL EVALUATION, PHYSICIAN WRlTTEN OPINION Date)(_J3-tO·./D _ Employer:X=-IfffitiE DE"M.ol;{.:oN Ernploye~ Namcy;' tv! i c.#.. A· tJ i uk {s ,~, .. ' ';;"'~ ~'1:~~'~1 ;·\'~~:.~-}:i{<0;.b:1~~~\>;iHt3;W%':!)}iL~}R~~~Wiij1r;i~~WWZ-Nr~~~~~}~~i4~.@m~~vm};~:WJ;.t~~iXt~;~t:1f~%(:~:.~" :.:: :"',.! '.~ i,-,;:·~:,::".~,:, ~ ;,· .. '0~~;'-:~:b.'::((~tW:W~::M1~J.:~,~*W~~~t;~t?»s~~~~~~.?t&iWlm'@%;'!~fllii-~ii~%Wjk~\:.""'.oh., .• z<t-~1-.:W.-.;¢<;.'t~h'~::,:th'f~,):.: t::~\x;:·"h ~:" . Initial Exatnination~ Antl\lal/Follow u;T; Medical Qucstiorumire completed for initinl exam ( ) Abbrevioted Questionnaire completcd fol' annual/follow up ( ) ciJest X-Ray (}({YES PH WNL () YES ( )NO ()NO I have according to l;'edcral Standard 29 CPR 191 0.1 001 and/or 29 erR 1926.58 physically examined and reviewed the mcc!iclli data of the above numed employee. I~ThiS employee elln wear a NlOSIIIMSHA approved negative or positive pressure respirator without IN! producing ~ardiopulmollary stress dangeJ'ollS to his/her health. () Thi, employee cannot wear a NIOSHIMSHA approved negative or positive pressure respirator without b/' produdng cardiopulmonary stress thtit Jhlly endangel' the health of this em[lloyee. \ A The employee has no evidence of'lsbes\os related disease. ( ) The employe!; has evidCnc() of asbestos related disease. THE EMPLOYEE HAS BEEN ADVISEr) OF THE RESlJl :rs OF THE EVALUATION AN]) HAS BEEN GlVEN AN EXPLANAT10N OF MEDlCAL CONDITIONS THAT MAY RESULT FROM ASBESTOS EXl'OS(JRF., AND OF THE lNGREASBD RISK OF LUNG CANCER ATTRlJ3UTABLE TO THE COMBNU. EFFECT OF SMOKING AND I\SBIlSTOS eXPOSURE. EXAMINERS Sl T g~ltr1rr- '-~----------'- DATE A:rhFJ{O.t Medico! c:"lYlflllllfMIOplllfa.1 ()1IS1'J1 7 (tiN;; ( , , Ha Occupa!ionlll Medicine T and Rehabilifation Respirntor Fitness EYaiuatioll. . . Name: _-----:Jv1_·.:....i_wt..:..-.~_· .-:A..:..·--.:......N=-'-'-cA--..:··~=-I.:.....f '_. _. ______ _ EmplOye,:~-..-:4..-'.;.!.{'l-e.;..i "'.:..:...:_..,!,O,-,t:o.:lM~o.:...(.;..,' -hl.:.::' o.:...rJ,, ______ ~_~ ___ _ humed. Dangerous _lncr. Temperature _ Oxygen-deficient _Increased humidity _Other. _________ ._~ ________ ~ ___ ~_ RC"'Piralor type: Cartridge type~. ______ ~ __ _ Chcckall that apply: ~f-face air purifying 'ull-face air purifying _Low-pressure air supplying/purifying _SCBA _Organic _Dust _Other:. ___________________ ~ _____ _ II HOUlS used per day 7-[r/l.Il?>', or per month_ Work conditions, ___________ _ Exertion lcve!, ___________ _ Other expDsures: ________ ~ _________________ _ Prior respirator use;_ Y cs ~ In military service?_ Any problems?--=-_c-----;-__________________ _ (flt, leakage, dyspnea, etc.) ~amiliat' with respirator use and maintenance?: _______________ _ ·N , iTnc!ions in respirator usage. ~ pirator usage approved with the following restrictions: i unDO Clement J. nanso . .. --------~------\ Q" .....f.~CeMe# 34M! ]?-<-I, ---\ _No respirator usage approved due to ________________ _ r .r·;:u;p...J Physician Signature }krpjralar Flmns l!\'a!u[l/iOfl 011.'1911 (61"1 , , Spirometry Report Puritan-Bennett Renaissance II SIN: G070701118 ( 'erslon: 1.1.11 10: Hrure: HEAlTH ONE BRYANT DCC MED BEST 3 FVC/FVI. Rfl'lJl(f Height: 70" PIlyslclah: M<l: 341R5 Tcc.hoiciao: Session Date: Sessi on Time: Last Cal Check: Sensor COOO: 18Jperi:lLure: lOAUG2010 lO:42AM lOAUG2010 Gender: tHCHOLS MICAH MAil Weight: 1901BS Barometrlc Press: a:10905 68F 625mr11{J . 1.1;06 KNUDSON 83 Hed1ClJtion: 00'.9.: Clinical Format· PREIIED -lO:44AN ee,t Criteria: :;mo~cr: 110 Ethoicity/CorNlCtion: f.AIIr . .o\STM * Indicat.es Best Va1ue SUM BTl':> Correctlon: 100.OX Normals: <: Indicates Below II.N ~'ilIRfMEH I ll!,; lI:W.1 !ewI Irial ? Id.i1L1 p,.,,~ ill III A 6.11' 116 6.09 6.14 5.23 FEV! (I) A 4.77* 97 4.19 4.12 4.33 f[VIZ 69*< 83 69 < 61 < 83 FFF25-75 (LIS) 3.06' 67 3.11 2.92 4.b5 PEf(LlS) 1.97." 82 1.66 7.59 9.55 fET (5) 10.67' 9.75 10.25 R<:port 5l1Ttlary. Pre Bed: Tests 3 J\ocoptoble 3 Repro<fucible 2 FVC VAA: 2311l .oilS Inte')lrel.<llion: Coimle11L: PREMED H······ ~ oJ 12 .. -; -19. " 0 B .... .. G " ~ ~ 2 j \I 11 1 2 3 !!l .5 CM=IL ,., " " " u "' ··:····:·····LIlGEHD • .. : .... : ..... -Pre 3 . : :-Pre 2 •.......•.. '-(IrQ 1 _ .. fred 4 5 6 'I 8 9 10 lJDLUNE (I.) ................ ............... . . --.', ~ ........ -;;-;:;::; .. :.-................... . ·····r········r .. ................ . 1 2 3 5 6 ? B 1 eM=I!! 4.24 3.42 72 fEVl VJ\H: 28ML Pfr VAA: 2531111S . ..................... . . .......................... . . ....................... . ...................... ................................. :LEGBND' .-Prtl .-Pro :---Pt'a ..•• Prad 10 11 12 13 14 15 TlM6 (8) Page. 1 of 1 ~OccupatiQnalMediclne Spirometry y 8./0 /0 ... r-T and Rehabiliroltioll Ibate: . ( ~N~--------------~--~--------~co-m~-y----~~----------arne M ,''-'j-{. 4 AI r ct,,{ ) paf] fllf!('tV'; f)t?MC(~-h'oA/ " \ Date of Birth Age Temperature Sex .~ Height: $ocial Seourity No, L.. tg.% M-e ' 0" 3'1 1'-2.'f(j '31 'S"'eJ:; Actual Value % of Predicted Value ... r:v<;: liters liters . '11 FEV 1 IitGrs liters !. FEV1iFVC % 75% L-~~ __ ~~~~ ______ ~ RESPIRATOR CLEARANCE GUIDELINES l)() • , !lO 60 "11\ ~ GO SO 010 00 20 ,~~! III' ~ " J ~roved o Not Approved DATE ./ .'\ 1\ 'J;t~., 1':';';:;'0i? J ~ .1·~,1 :Ilm: . ' t··:~;:;: IM'PROVIDI l/ ~~~ . ~i;i:::::::::::"""":""'5Bf:j l'. ..; .. '.i!' ~ ... ~:::'J t:· , ',,' 's( I IS I 1 1 lo AnENDING PHYSICIAN I PROVIDER OHS/912 10/00 AsbestosJRespirator Phvsical Form ( Name: Social SecUrity #: 2-1-(0·;1· S/j3S" Date: 'C> • to ,(t, I'vIIc..4U fl· N/0f.ovS .. _ ... WorkVisa#: Employer: 41 piNt f) {::VvW1; .{;. N Present Occupation~ /;;6 Highest grade completed in '. 01"7D--school? J 2.-# Yrs Employer Address: City: lIrvp;jr'; State: Co Zip Code Dale of Birth: Place of Birth: N.·G, Male~aleO White ~ 0 Indian 0 Black 0 Hispanic 0 t; '/S'1'C Cf1.eENSPt<f'<> Other 0 . Please check the appropriate box Exam Complete A, B, C as noted Height IJ t)«(, J;dght (?Oif::ru'se (pOt:. Asbestos Physical Ef:Complete A,B,C Blood Pressure: IU:? Respiration: IS-- Respirator Physical !'tCompletc A,B Lungs: T[=f7W ~, I Heart: . I ( .1H1U"- Abdomen: LAt»< A. Medical History Neck: { I CiI!IA' ~, Supplement to Respirator Questionnaire 1910.134 (e)(2)(i): Nose: ~I~ Have you evcrsmoked? '/ vi Yes~_·_ Respirator Medica} Questionnaire completed and reviewed 0 How much per day? oz... lit' < """ Have you quit smoking? YesV'Fio __ PUlmOnaryFu~i/U'if~ If answer is yes indicate date quit: 11-N . 'z...."o B FVC VUFEV ~ . Actual Ac 1___ Actual __ % Do you consider yourself in good health? YesV'ffo __ Predicfed Predicted Predicted % IF NOT, STATE REASON: PFTRelated Commcn~: ~ -- Do you have any questions or concerns regarding how you answered? the respirator questionnaire? Yes _NO'=:::::: . ~~ If yes please explain? "~X",.v_ I ~fi~RrI'-( X-RaYlntelJ'r~.ta~onby: ,rfadlol0t't 0Q!-r~ .10M B. Family History: Were either afyaur natural parents ever told by a doctor that they bad 7'fj(JI (J"'" , Q It" -.-I a chronic lung condition such as: .1 :-;-'-• • .~ . " ~ Nt. . fiN. II ti/5,HV '" I~ ..I YO IV"'U vf Father Mother A~ ~51f 7! Yes No NA Yes No NA vC>O ~~I r Chronic bronchitis? o !LV 0 0 ·0 Other Laboratory Data: J/NM7 ~ Emphysema? o \9'" 0 0 0 Astil111a? o rr 0 o • 0 Lung cancer? 0jJ"0 0 kYO Other chest conditions? /d/O 0 /dO 0 ""'~-F~ Is parent currently alive? 0 0 0 0 0 0 Ifno) age at death? Specific cause of death? Father: Mother: Asbestos/Smoking Explanation: C, Asbestos Hislory: , , This employee has been advised oillie results of this examination and has Do you currently or have you in tIle past worked in these mdustnes"l been given an explanation ofme<1ical conditions that may result from Yes NoNA Yrs Asbeslos exposure, Md the Increased risk of lung CMcer a({ribu(,hle to IfYes. indicate Years from-To: Example(1995-~O) the combined effec's of smoking andPtt9 Worked in aMine? 0 ~ Worked in Foundry? 0 0 Date of Exam: ~l Worked with Pottery? 0 id"'o Worked in Cotton or Flax Hemp Mill? O:rg Signature ofPhysicianfFrovider: 1 Worked wHh Asbestos? 0 ~ Have you ever been exposed to Asbestos? 0 0 . . . .In. J ); 40Jv. ' ,./ . ~ ~ans~\i I>f'S' \ 'plam: ~ Provider: ~~rl en \f~~llttld de Copy to Empl 'cr and Employe 0 \\i~e\i~e C .. -.... , '.:: . : ... : . : .. . ... ••••• J i ..... ,: . , ... ....... :-.' -.~. '{:~. . .; .. . : ... :\ . , :.:~ '.' .... ~ " :->; • .j .•• -•... ..... ; .. .:.> ..... . ....• . ... .. .......... INTERNATIONAL Environmental and Safety Training L.LC. 720 Billings street Unit F Aurora, Colorado 80011 Phone # (720) 859-3134 Fax # (720) 859-0660 CE'RTIJ"I'ES T3f.JtT DANNY" RALSTON Has successfully completed The EPA-APPROVED AHERA ANNUAL ASBESTOS REFRESHER COURSE for WORKER And passed the requirements examination in that discipline This course is EPA-Approved under Section 206 of the Toxic Substance Control Act (TSCA) Course Date No. Hours Certificate No. 06/05/10 8 C00601O-27A W . 06/05/11 This course meets the requirements of AQCCReg. #8 h :J /:/ . "...' // ~ d*f1((;f " {/~Q~ , .' Instructor Name: Horacio Cuevas " Concentra Medical Centers 1730 Blake 51 Suite 100 Denver, CO 80202 Phone: (303) 296-2273 Fax: (303) 296-8330 EMPLOYER AUTHORIZATION AND INFORMATION FOR RESPIRATORY EVALUATION I1PLOYER TO COMPLETE THE FOLLOWING: I Address: Employee Name: Ralston, Danny L. 20061 E Bel/wood Dr "C:;:E:..:NT.:.;E::.:N.:.:N;.:IA:..:;L=-______ .;::C.;::0 ___ ""80015 Employer: Monarch Site Services Employee SSN: XXX-XX-3538 heck Type of Resplrator(s) To Be Used !Check y' ALL that apply) 1 Air-purifying (non-powered) D Air-purifying (powered) o Atmosphere supplying Respirator !,xtent of Useage I (Check y' ALL that apply) I D On a daily basis __ Total Hours o Occasionally -but not more than l\Nice a week __ Total Hours o Rarely -or for Emergency situations only Total Hours o Combination air-line and SCBA o Continous-Flow Respirator o Supplied-Air Respirator "xpected Physical Effort Required I !Check y' ALL that apply) 1 D Light D Moderate D Heavy o Open Circuit SCBA D Closed Circuit SCBA o Dust Mask D 1/2 Face with Canisters D Full Face with Canisters "xposure to Hazardous Materials If ~C"'h;--e-c"'"k-y'~A"'"L7L-,t,-ha-Ct-a-p-p7Iy7)' Make: Model: Cartridge: ___ _ peelal Work Conditions Check y' ALL That Apply When Wearing Respirator) D High Places D Enclosed Places o Protective Clothing D Arsenic D Coke Oven DCadmlum D Methylene Chloride D Textiles o Benzene D Cotton Seed 1 Dust D Formaldehyde D Lead D Chromium o Temperature Extremes DMosUyCold o Other: ___ --.=-_____ --=;--__ ----.=-___ _ o MosUy Hot Other(s): ________________ _ DHAND CARRIED D MAILED D OTHER Questionare will be: EVALUATION AUTHORIZATION BY: __ -,--_____ _ Signature of Employer Representative. DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE PLHCP 1 WRITIEN STATEMENT for RESPIRATORS (EMPLOYER) p=H~Y-=-SI"'CccIA'"'N"'W=IL·L--;C"'O'"M .. P"'L"E"'T"'E""T""'H"'E"F"'O"L"LO'"W=IN=G I This report may conlain confidential medical Information and Is Intended for the designated employer contact only, The Americans With Disabilities Act \) Imposes very strict limitations on the use of Information obtaIned during physical examination of qualified Individuals with disabUities. AU Information .. t be col1ecled and maintained on separate fonns. In seperate fifes, and must be treated as a confKfentlal medical record, with the (oHowing exceptions: • Supervisors and managers may be informed about necessary reslricllons on the work or duties of an employee and necessary actommodaUons . • First aid and safety personnel may be Informed, when appropriate. if the dlsablJlty'mlght require emergency trealment. Based upon my findings. I have determined that this Individual [Check:.?' ALL that apply) I , ~pk:lyea must schedule a medical examination with Concentra Medical Centers ~iass I -No Restrictions on Respirator Use prior to respirator approval and usage. D Class" -Some Specific Use Restrictions 0 To be used for Emergency Response or Escape Only o Other._" _______ _ DbJass III -Respirator Use Is NOT PERMllTED o Further Testing I Evaluation is Required. 2 o Fit Test Required 0 FJt Test Performed Satisfaclorily o Fit Test Perfonned Unsatisfactorily 0 Rt Test NOT Performed al: Cooceotra Medical Centers o Special prescription eyewear needed 10 accommodate respirator 0 Special prescription eyewear needed to accommodate respirator Dfaci81 hair needs to be shaved to assure tight sea! on certal~ face masks. Physician or other LIcensed Healthcare professional ~mp!oyee must seek further medical evaluation by a private physician who must submit a report to Concentra Medical Centers of hlslher findings to y' ALL that apply) he above individual HAS been examined for respirator fitness In accordance \-'lith 29 CFR 1910.134. this limited evaluation .Is speCific to respirator use only. Employees should be Instrucled to report any difficulties In using respirators or change of any physical status to their supervisor or physiCian. This evaluation Included the Respiratory QUesliOMaire outlined In 29 CFR 1910.134. o The above Individual ~ been examined by me for respirator fitness. The employee's medical evaluation consisted of a review of OSHA's Medical Evaluation Questionnaire In Appendix C Part A Section 2. In accordance with 29 CfR 1910.134, this limited evaluation Is specific to respirator use only. Employees would be Instructed ht.eport any difficulties In usIng respirators or change of any physical status to their supervisor or phYSician. This evaluation included the Respiratory QUestionnaire o ioed in 29 CfR 1910.134. n accordance with specifiC OSHA requirements, I have Informed the above named individual oftha resuIis of thl evaluation and of any medical conditions resulting from I may requIre further explanation or treatment. Where applicable. the above named Individual h be Informed of the Increased risk of lung cancer e combined effect o·f S oking and asbestos. lead andlor other chemical exposure(s). ~tL+-+~l Expires On Page 1 of 1 Print Date: 06119/2010 To be maintained In the employee's file with a copy to the employee Revision Date: 06/29/1999 ( Concentra Medical Centers 1730 Blake St Suite 100 Denver, CO 80202 Phone: (303) 296-2273 Fax: (303) 296..s330 Medical Surveillance -Asbestos Service Date: 06/19/2010 Patient: Ralslon, Danny L. Job Title: __________ _ SSN: XXX-XX-3538 DOS: 06/22/1969 Gender: M ------------Marital Status: .ccS __________ _ Employer: Monarch Site Services Address: 1220 E Hampden ENGLEWOOD, CO 80113 Job Contact: Paige Lentz ~~-~--------Address: 20061 E Bellwood Dr Role: Primary CENTENNIAL, CO 80015 Phone: (303) 355-1778 Ext.: Home Phone: (623) 518-7248 Fax: (303) 355-1771 Work Phone: Ext.: --------~-----Race: ASIAN BLACK HISPANIC INDIAN WHITE OTHER The above individual was seen on 06119/2010 in accordance with: ___ 29 CFR 1926.1101. ___ 40 CFR 763.121. ing was performed: Completion and review of the standardized medical questionnaire and work history with special emphasis directed to the pulmonary, cardiovascular, and gastrointestinal systems per Appendix D in 1926.1101. D Review of the employer's description of: this employee's duties as they relate to the employee's exposure, the employee's representative or anticipated exposure level, and personal protection equipment to be utilized by the employee. D Review of Information from previous medical examinations if available. ~ physical examination with emphasis upon the pulmonary, cardiovascular, and gastrointestinal systems. / ~ A pulmonary func. tion test of forced vital capacity (FVC) and forced expiratory volume at one second (FEV 1) In accordance / '--' with NIOSH and ATS standards. ~ A chest roentgenogram, posten or-anterior, 14x17 Inches (or current film on file) with interpretation in accordance with 29 / -=-CFR 1926.1101. (M)(2)(Ii)(C). ~OTE: According to 29 CFR 1926.1101 (M)(2)(ii)(C), it is up to the discretion of the physician whether or not a chest X-ray ~ulred. /" ~ employee was infonned by the physician of the results of the exam and of any medical conditions that may result from asbestos exposure including the increased fisk of lung cancer atlrtbutable to the combined effect of smoking and asbestos exposure. Unless otherwise noted below, this evaluation Indicates that there are no detected medical conditions that would place the employee at an increased risk of matenal health Impairment from exposure to asbestos, and there are no recommended limitations on the employee concerning the use of personal protective equipment or respirator. Comments or limitations (If any): Date valuation ~ Asbestos Medical Surveillance Page 1 of1 Revision Date: 07/21/1999 ( Concentra Medical Centers 1730 Blake St Suite 100 Denver. CO 80202 Phone: (303) 296·2273 Fax: (303) 296·8330 Physician Respiratory Examination Record Service Date: 0611912010 Patient Name: Ralston Danny L Address: 20061 E Bellwood Dr CENTENNIAL CO 80015 SSN: XXX-XX-3538 j EXAMINATION I Height Weight Pulse Temperature Blood Pressure Respiration Heart 'ungs lrs Ear Drums Nose Buccal Cavity Pharynx Musculoskeletal Hernia 6' 11 '-t ~L{ AB AB AB AB AB AB AB AB YES IRA TOR FIT TEST performed at Concentra Medical Centers DPass DFaii D Return to Clinic on At: am/pm This Examination Expires on: b ~ l'i i L ! O . (da!) .~ ician's Signa 1 Physician's Name (print) Gender: Male Day Time Phone: ( ) x Night Time Phone: (623) 518-7248 Race: (Circle One) Asian / Black / Hispanic Indian / White / Other Employer: Monarch Site Services ITESTlNGj Testing necessary for 29 CFR 1910.134 does not include testing necessary for other OSHA med/cal surveillance: EKG Performed YES NO • Commentsc-____________ _ Spirometry Performed • Spirometry Results Attached YES NO YES NO • Comments:. _____________ _ Chest x-ray Performed • Results: • # of views • X-Ray # WNL YES NO YES NO • Comments:. _____________ _ B-reader Required YES NO • Date sent: • Results: Vision Testing YES NO • Right Eye Far Near • Left Eye Far Near • Color • Depth Perception • Peripheral Audiometric Test Ordered YES NO • Results: Within Range Out of Range • Comments:..: ____________ _ Blood Tests Ordered YES NO • Tests Ordered,~: ---;-:-::c:-:-:::----:,--,--,-=-- • Results: Within Range Out of Range • Comments.: _____________ _ Urinalysis Ordered • Results: YES NO Within Range Out of Range • Comments::.. ____________ _ To be maintained In employee's medical record Page 1 of 1 Print Date: 06119/2010 ·.·INTERNtTIONAL ....• . ' . . ErivironmehtalandSafety Training L,LC. . 720 'Billings street UnIt F'" . . ... Aurora,Colorido 80011" Phone # (720) 859 .. 31~4 Fad (720) 859-0660 .. ' . . . Bassuccessfully completed . The EPA-APPROVED AllERA ASBESTOS COURSE for WORKER And passed the requirements examination in that discipline . T4iscoi!rse is EPA-Approved under Section 206 of the Course Date . --. . . No. Hours CertHic~teNo ....•.. . 'Toxic 8ubstanceCoiltrol Act (TSCA) . 03/07-10/11 32 .C0031011-09 03/10/12 This coUI'se meets . the requirements of AQCC Reg. #8 '. . •. ~ Instructor Name: Horacio Cuevas .• .uu I:. ...... III.1t1 "'''loW, .... ¥utI<' I III 'hoNn'ntI. ,:0l1li:"'"1 I Respirator Fitness Letter .... __ ... ....... ' 7, ..... Dlte: _3 ...... /t-:-,s_--'-f _I (_ Dear Ileader. Thl.lcner Is to certify that fL e... '3 h ().f c/ J (lui> e 4"7" Is, or I. not, fit 10 wear I mpirator durin, performance of daily job duties per OSHA 1910.134. This decision II after recent completion ofa respirator miew. I. The patient Is: ~ Fit to wear an air·purifyin& respirator wllile perfonnin& . current jobdutles. • CUnfit Medical limitations or wortcpl," conditiOni will Include: W:: J-1M-'<.. ~ e@~1<1eZL\ I (j2 c c'1~a ~U e C (vi( 2. 3. '@. No fIuther mediCI! evaluitionille required It this time. D Fwthcr medical evaluatiOnille needed It this time, those follow up evaluallons lie: • , 3. On _______ --"(date), the pltient and the employer were provided with I written copy ofthi. recommendation. . .. - , , f; \. , , , " • ·PHYSICIAN'S STATEMENt- Adeleaelam to ~e AppUeaUoll ror CtrtlRcadoa U ID Asbestos Worker. Instruct". I. Ie •• pllca,1: I. C ' .... I t ......... w. ..... lie .... CIIICIIJ .... " •• ,.. ... Ikllil. " J. A'" !WI"'''' wi .. die pIt)'IIcIu', .nsiMIlII ........... ,..."IIa'. W .T"'" lisbJd lobel' S ,.;. NdhlA111 _5~S~4~0~X~~~\Q~~ .. ~~ ________________ _ I, ' ... ~~. . . ... CIIf •• llfe. JXoyC:I CO. »0239 .... S r 1&)11 ' =, 52-;11;4-170: , ...................................................................................... 1 ••••• rnltmstll!! It It g •• lnlp, ,tnlsllP; I. C ,It .... ,.,.·· "1'111 II' .... '. 2- J. a... .............. ,., ert ......... IlIrC .. 1IIc ... nn. '" .rse' . ~ DIll· WIll ...... die ..,..W ........ CIa at."uc.. PHYSICIAN'S STA'IIMINT: " . D .... ., ""' ..... rdle cwIC.IIC:lllhrdll ~ .... cd ........ '1IcrcIIr 1If101c1n1lcf hi WOIl."!IIlt projtcII. I ~r, .... , &III cvm:nsl, lkun'leawactJcc IMIkIIc. ~j[rt • . . I I I I '---'1----, o· _ ....... , E ,14U, I ASBESTOS PHYSICAL FORM _, o. ~I L I PIe ... check tht appropriate box: Complet. A. B. C .s no1ed Asbestos Ph)'sIca1 a Complete A. B ancI C Respiralor Pbysical D Complete AlB Only P A.RT A: Mecllcal Hlstol'1 PART}': F.mII, Historr -PART C: AlbalOl HIs,orr (SupplCIMIIIlo mplnlar cpclli1lauw) :~~~ .~':;IOII Do ~ _111, or 11m "" III the ,.. -W II IhHe 1UnIa? Hlw)'O\I nwllllCllltd? "'-"'.::::No . How III ...... " o;(a~:z !/ de) FI' .. , ' II. YIAQ 1111 ......... ' ,F Hlw)'O\I !pit tIIOIdna? YII It,., IDdiclle"lt cpIt ~ 11l1li ,t I wiD 1/ Do~~U'ID.ood k nUH~· / ~, . _No '''",1\I1e 7' ~ be, ~ bnc U)' cpeIII_ Iff _III 10 ,It __ IA !.IL (ElplalD) ftJII'dlD& bow )'OIlIInIetft die /) ~ .. respftlar queIt'-elre? YII ~o- If)'el, aplaln g:'!::r:::M., '1:10 E:nrnlDldoll ifeitrbt '1 ~1~' We/rid I~ hllllODl!)' Faactloa Tes! 'u\Je r, I BIoocIPr_ I f.3/'!/ 1'l J ~~~~ FEVJ m~ temnllioa 'I Lana ~:~a~ lean AbdPmaI leell: Now PFT_II ' ·.esplnltor Medlcll QueltiOlmllre completed ucI mleud YES NO Olcst X-by' VIeW X-byFlla' ~EaplaMtlan: X-IbY~~CI.I~,,~ D~~I-,llB Reader a ThlIIIII= hat. aclvlsed otlhen:rults otllllUJMIIlnatloa / <'><A'-o' l' '"" "?' 0 nI,. been WII. ap\lllllloa otme&c.l ocnIiIlaa IN!,.., eLF ~. ~ noult rro. AJheItOl Clpalln, IIIId \he loa r ! rill or .... _ 1IIn'bulablc 10 \he caoblned cIr_ otlmOkln. nlllbcllOl ClpGIIn /I, lOr Cunmc:",bI yo -. Other LaboralDl)' OIg tl..!/ J . ~OI~.~ 1171 II .:. tf1I./\/i2. . .1 (b ,G 'NO CIJ.-.-:it JrX SlJllllllle '" I "'---"" INTERNATIONAL Environmental & Safety Training 720£lIlIngs Street Unlti', Aurora, Colorado 80011 Phone 720 859 3134 Qualitative Fit Test Results Employee Name if:S hJd 'L,be1.'$ II) # < SS# - -5t(, '0 Fit Tester Teclmician: Horacio Cuevas Step I:ru 1 Ex. 2 Test 3 Ex. 4 Test 5 Test 6 Ex. 7 Test 8 . Test 9 Ex. 10 Test 11 Ex. 12 Test 13 Ex. 14 Test 15 Ex. 16 Test 17 Ex. 18 Test Qualitative Fit Test Passed:· Testing Agent Used: Descri))tion Breathing Face Forward Side to Side Head Left HeadRight Head Up & I)own Head up Head down Reading Face Forward Grimace Face Forward Bend at Waist Face Forward Jog in Place Face Fonvard Re-don Respirator Face Forward ~ Test I)ate: 3 I;ii72oll ~ ~ ------+~/ --;r--,/f: ----~---7/ Z No Banana oil Saccharin Respirator Model: .1;(J1ft.1~'t:J,,-!:5'2~--<~~~'-.-;~~L-I Half FaeeNr Purifying Full faee AirPurlfying Respirator Size: SMALL ---"-=-~ Limitation ofthe selecled respirator Putting on the respirator ' Wearing the respirator Inspecting the respirator Respirator Protection Program Maintenance of respirator Use of air purifYing respirator Purpose of medical evaluation Proper fit test techniques I illlderstandtheuse, care and inspection ofthe respirator{s) I may use and have had the oppoliunity to wear and fit test the respirator{s) I may use. Signatme Fit Tester Teclmician: -='*'_L-_____________ ~ Expiration I)ate: ~ E.J Zt) I Z-- ~; - £38C1d eOO'd 'lV.LO.L 0990 6£8 02L INIt:J~l ('jN3 It:JNOIlt:JN~31NI 6£':L0 0T02'9I-E PHYSICrAN'S WRITTEN OPINION -ASBESTOS Applicant's Name: ~:?!,~l.~ 'fJ,iv~~, AddrO$S: /4, (:£tl~ £ y~3 51;.c.:t4 , _ . .' .... . I fheabovo namedwi\$ s~en by me on l"~/t:TI > lIl1d in accordance wi(h HII aPJlllcabl~ pOltion$ of )S'HA 'sAsbestos Stllndard for the Construotion Industry, 29 CJ7R 1926,110 I. with which r 11m tlunillar,l /Jnve indi~ItNd by ny initials, that T have 'pertornwd th¢ following, I, ~ Reviewed with this individual, hill/her completed OSHA Sll1lldardil!~~ Medical Questionnairlllmd Work Ristory, directed towlU'OS the plllmonary, 'oardiovasoular, lU1d gastrointestinal, $yswmi and L ~" RQyiewed tho (lrnpJoy~r'8 description of this individunl's duties us they reln!e to. Il.~bcstos exposure, (he antioipated exposure lovel, the personal proteoliye and resplrhlory·equljimont to be utlJi:.:~d by the . Individual; Md any additional medioal information resulting from previous examlnaliolls; nnd ;, -/'CondllOtcd If physloal ~xanl/llation oftbls Individual wl(h ~mphasls on the pulmonury. cru'diovAaculllr, and glISlrointestinal8ystems, Inoludlng II PUlmOllAIY funcdoll test of forced vital capuaily (!lVe) ~lld / forced eXpiratory VOlu.me at one second (PBY.l) and , " __ Determillod·that II ch~st roent$c/l(')gram was _ was not ~lrCd as npart efthis ~xill1llnation, (if requIred, Ille x-ray was taken (\Jld rend in accordance wllh Appendix E of the Asbestes Standard)i and / Dete1'minod that this lndividUlll may ~-not ~" usc II respiratory device while performinG his/her /' reqllil'OsiumploYlllellt servicos; and, .' _,r·_-.. · . , ___ !nlbrmod this individual that Thaw _ have not ~t~d n medlclll ~ondjtJol1 which wo~ld place "'/ thi~ individual at nil InoTI;lHsed r;~k of material health hupslrlllen! from exposure to. asbo~tOsjlmd '_ /,nformed this individual of the rcsultseflllY examination and of any medIcal. oonditlOll Ihlllmay I'esult / :from this indivIdual's exposure to Mhestos; MO . Tnfonncd this individual of the h~al!l(rlsks liwolved in S1l10~ing. of the synergistic relatlonshlp b~tween olgarette smoking and aib~b~~lf~p.osure ill producing lung oancOr, Hnd tlwt cCAsa(/on of smokJng will reduoe tho risk of IWlg ~ancel" . ' ommOnls and/or rAmitations (if allY): . >hysi6fiGJ!s Printed Name) , (Physiclan's Slgna{ure)" OcoMed COlorado, LlC $449 N, Chambers Rd" Ste, B Aurora, CO 80011 Ph; 720-259-813(1 Fax: 720.S5g.S2M (Physician's Addtess) Respiratory 'Protection FII Test HccQrd ;·."!'''.r,'' ._ DQ<2I..L.\:.Q..&~rifn£.~K Respiralor ID (1I.lnili8Is. CIC.).. __ '-L,,;ulaClurors Name' .Mrr.j:~~<if<l±,,% . . Mo~eI/Size: 3.:1'OO? 01,_)1'1 ! ,-_.;, j'gJ Neg""ve Pressure Check ~ Imlanl Smoke QualHalive I csl ~ POSII.vl' Pressure Check 0 Isoamyl ACe!ale Oualiralive Tesl ,.-, () h __ • I or ',-,,'" ,"ille« $hall pcrft>ml Ihe (ollowlng exercises tn Ihe order pre,'cribed. CHECK EACH ONE l5.Q; Nom!.1 Brealitll1g In a floml.1 slanding posilion. wilhoullalking. Ihe subjeci shall brealhe nomlUlI, ~ 1)(..;" Brc,ulling In a nonnaJ standing position. (he subjeci shnll brea!he slowly lind deeply lakin!! cuullon so tiS not to hyPerventilafe. .. _- _ .. '---'---'---'---.-Slandlfl~ in place .. fhe $Ubjeci shall :;lowIY-fllrfl 1;-;;Il~~'rt;~~Tl~;,-,-;~~"~d~'~~ >;I(k tlf.'I\~~~;;-·-p;( Il;rIllO!! 1-/1.-;1(/ Side- "I,: .. : fhe eXlfemt:' POSIfIOIlS all each side. The head stud! he held af eXlfemt" nWIIH::tl!iifJly~!I the subjeci can .nhale al each side. Sranding in place. the subjecl sh.1I .Iow/y mO\lc h.islher head up and down. The J:2Q ,\'I\lVI/I.!.! Jiciid Up & l}cI\\ II subjeci shall be instructed 10 inhale in the up posilion (i.e. when looking loward Ihe ceiling. %--~--~- I ilU~lnt! The subject shall talk out loud slowly and loud -enough so as 10 be heard clearly by Ihe Icst conductor. The subject can read from a prepared lex! such as the Rainbow I'assage (see reverse page), count bllckward from 100, or recile a mel)1orized poem or song. I: ' "'"'"'' The tesl subjecl shall grimace by smiling or frowning. (fhls.appl/cs only to QNFT -- testing: It Is not performed for QLFT.) • ~k",r.n!: (".-er The lest subjeci shall bend at the waisl as if he/she were to lauch l11s/hef IDes. Joggmg tn place shall be subslituled for Ihis e>lercise in Ihose tesl environments such as" r'PK~;;~:;-Brcalh.ng shroud lyPe QU;T O! QNI~r unils (hal_do not pennil bending OVer'l Ihe watS. Same ilS Firsr Exercls(" -- '.< J I!-htch .e51 exerCIse shall be perfonncd for I minule exccpl grima,:" r 15 seconds) The 'cSI 'U"JC~I 'hall he _ .u.:=-I;l'llcd h~' (he 1~::;I"t)nduc(Or regarding C'Clm fort anile respJral<>r UpOII cvmplc! IOn () r Iht' protocol. '1 r II ha~ hC:CIlIIIl' u.t,h;f.,TPlJbk. another model or respirafOl' shaH be [ned. 'Ole respirator shnll nO! be ltdjus(cd ollce Ih~' Iii 11;".':1 CX~'((J')t"­ '~\',-'1I1 '\Il~ iHhu$fnll:llf!-VOid fhl.' 1C;.s.1. nod the til les! must be rcpCflIt:d. ; "'1'1,,, .. .-hnc/cd on funr/amen,"1 pnne.plcs of resplralory proleClioll. lise, Inspeclion, clculllflg, mamlcnancc. ant! .', 'r<l~~' o( cqUlpmcnl X-Y c.s _' .• ~ .. _ No ,'lTedIVt' Icnses required for nonnal work tasks: ___ .__ Yes -X-. No .,"'. wh,d. doc, employee_ use" Prescriplion safelY glasses, Prescriplion safety goggles. Respirator specHlcles ; .1. ;,I~ .. :hol!':KI(.TI;\II~S prL'YCnllllg seal (Be.:1rd, miSSing demure:i,. cle.): Yes Yes ! 1I ... :rd)~ cl'mfy Ihallhc 5uh)cCf employee has been iii (cslcd III uccordrlllCC will) (he OSt-IA Resptraton Pro/cnwlI \!,/I/{Iarr/:I) CFR /9/fJ 34, App(~/Idi.'( A "Fit Tl'sltllg PrOCN/urp.\···. (Rei' /I/?l<}(<) The Rc:wfl~ of rhe f .... sl(s}lndicllfc{/ IhH! liw ..uO}C(.'I employe," 1$ acccplcd IX ). rc)ccfcd ("' ,. ) f()f work ilssignnl<'n(:> rc.quiring Sf><.''':-Ilied (CSfm;IIN\ ''''<l-'~':H'II ~1('·\1L:('·'" INTERNATIONAL Environmental and Safety Tl"aining L.LC. 720 Billings street Unit F Aurora, Colorado 80011 Phone # (720) 859-3134 Fax # (720) 859-0660 RICARDO M. CARDOZA Has successfully completed The EPA-APPROVED AHERA ANNUAL ASBESTOS REFRESHER COURSE for WORKER And passed the requirements examination in that discipline This course is EPA-Approved under Sectio1l206 of the Toxic Substance Control Act (TSCA) Course Date No. Hours Certificate No. 09/11110 8 C0091110-09A W 09111/11 This course meets the requirements of AQCCReg.#8 Instructor Name: Horacio Cuevas • I Respirator Fitness letleU Dear ~eader: This letter is to certify that ,IG ~ rd 0 a .. &. "I is, or Is no~ fit to we~r a respirator during performance of dally Job duties per OSHA 1910.134. Tlli6 deCision Is after recent completlon of a respirator review. 1. The patient iS~IL Untit . . 10 wear an air-purifYing ' .. plrator whlle performing CI.lrrent job dulles. 2. Ml(!dlcalllmiiatlons or workplillce conditions will Include: _ 3_ 4. ~o further medical evaluatlon~ are required at this tlme. .- _Further medical evaluatlons are needed at this Ume, those follOw uP. evaluatlons are: =--:-,,'-;;;1'--:?-l ,-t;> _. (date), the patient and the employer Were a written copy· f this recommMdatlon These results will remain confidentiGI, and they will be kept on file In our office. / .• £S-~,~~~ .. $4/ {; (Signature of PhysiCian) "7'" tate !./ ~V. - DeeMed Colorado, LLC 560 E Thornlon Parkway, Suite 110 Tl'Iornton, CO 80229 OccMed Coforado, LLC 3449 Ch<lmbers Road, Suile B Aurora, CO 80011 -'-'--10-3811d . -'" 2761 W. Oxford #7 • Englewood. CO 80110 . (303) '181-2318 • Fax (303) 781-3048 L.L.C. Qualitative Fit Test Results Employee Name [{'eA ft.'Do CA~~zA ID# __ tilbu~~o.~0~_ SS#_--:-;~;:\<--\ _;-: Test Date: 1+-' (J -11J Step . Description 1 2 : 3 Ex. Test Ex. Test Test Ex. Test Test Ex. Test Ex. Test Ex. Test Ex. Test, EX: Breathing Face Forward Side to Side Head Left HeadRight 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Test Head Up & Down Head Up Hea~Down Reading Face Forward Grimace Face Fonvard Bend at Waist Face Forward Jog in Place .Face Fonvard Re-don Respirator Face Fonvard .... ~. Qualitative Fit Test Passed: . Y . Testing Agent Used~ _Irritant srook , Respit:ator Model: ROf) N/JMif Ie-. "/ No Banana oil Saccharin IHalfFace Airpuri~ Fullface , . Re.pirator Protection PcogrlUll " Limitation /:lithe s~lected respirator Maintenance of respirator' ; , :Putting on the respirator Use of air purifying respirator Wearing the respirator Purpose ofmedica1 evaluation Inspecting the respirator Proper fit test techniques I J,lll.derstand the usc$ care and inspection oftherespirator(s) I may us.eand have bad the . opportunity to w(lar.wd fitte therespirator(s) I may use. Signature: :::::::;d~~~~=---------Fit Tester Employee Signature: ___________ ·_Expiration Date: Will112- INTERNATIONAL Envil"Onmental and Safety Training L.LC. 720 Billings street Unit F Aurora, Colorado 80011 Phone # (720) 859-3134 Fax # (720) 859-0660 CARLOS ZAMORA Has successfully compieted The EPA-ApPROVED AHEM ANNUAL ASBESTOS REFRESHER COURSE for WORKER And passed the requirements examination in that discipline Tllis course is EPA-Approved under Section 206 of the Toxic Substance Control Act (TSCA) Course Date No. Hours Celiificate No. 03/19/11 8 C0031911-11AWR 03/19112 This course meets the requirements of AQCC Reg. #8 Instructor Name: Horacia Cuevas " . INTERNA TIO NAt . l~nvironl\lentlll Hnd Safcty Training L.LC. 720 Billings street Unit F Anrora, Colorado 80011 Phonc # (720) 859"3134 Fax # (720) 859~066() CE11.:TIJ"I'ES'lJ{.Jl'l CA.RLOS ZAMORA. I-las sllccessfully completed The EPA-ApPROVED AI-IERA ANNUAL ASBESTOS REFRESHER COURSE for WOIumR And passed the requirements eX<lminati011 in that discipline This cOtil'se is I~PA-ApPl'ovcli under XCclion 206 urlhe Toxic Substance Contl'ol Act (TSCA) Coursc Date No. I-lours Certificate No_ 0311911 0 C003191 0-09A W 03119/11 This eourse meets the requirements or AQCC Reg. 118 Instructor Nance: Horacio Cuevas Health . .... ~ .. 0 ' W Occupational M~dicin~ '. \. . arid Re\\ab.ilitation :,. \ ,. . . , ASBESTOS OSHA 29 CFR 1910.1001129 CFR 1926.58 MEDICAL EVALUATION, I'll Y~I(I\N WRITTEN OPINION Employer: ___ --JN-"..J{\e.--'--_;.~ Employee Name: C?OI1 /vs Z"-'A"'"'I1!CL-"'O~/C."_'(l::.L..... _________ _ Initial Examination ( ) . AnnuallFollow Up W . •. Medical Questionlla(re completed for initial exam ( ) I Abbreviated Questionnaire c?mple~ for annuallfollow up Q Chest X-Ray ( ) yIiS ( iNo PFT WNL ({yES ( ) NO I have according to Federal Standard 29 CFR 1910.1001 ancJJor 29 CFR 1926.58 physically examined ;!"d re7iew d the medical data 'ofthe above named employee. ( This cmployee Can wear a NIOSHfMSHA approved negative or positive pressure respirator willi"liI producing cardiopulmonary stress dangerous to his/her health. (~lfG cmployee cannot wear a NIOSHiMSHA approvep negative or positive pressure respirator wil Ii, 111( producing cardiopulmonary stress that may endanger the health of this employee. . ( The employee has no evidence of asbestos related disease. () The employee has evidence of asbestos related disease. THE EMPLOYEE' HAS BEENADVISED.OFTHE·RESULTS OF THE EVALUATION AND HAS IlHI i GJVEN AN EXPLANATION OF MEDICAL CONDITIONS THAT MAY RESULT FROM ASBEST[ 1'; EXPOSURE, AND OF THE INCREASED RISK OF LUNG CANCER ATTRIBUTABLE TO TIlE ( 1;"1\1~\1-i EFFECT OF SMOKING AND STOS EXPOSURE. J. . Dunlde, MD DATE . 20 Bryant Street Denver, Colorado 80219 303:936-9700 Ilsbcs{o$ Medicol frt//IIiI!I· ,'I -":1" nl/'" .' Puritan·,Bennett Renaissance II SI.N: G07070l1l8 Version: 10: /lame: u.u .. ~. ,<-". v.u .. LlI\IIUt' acc MED nEST FVC/FVl PEPOHT ·lIeighL: 66" Physician: Ag~: !JOWlS· ledlllician: jess IOrI ua te : Session Time: Last Cal Check: ,. Serl!lur Code: Te!Tflerulure: lUMi\Y2010 J2:21PM 1 OMi\Y20 1 0 Gender: P' ":ation: 1e: 4498553982 , CARLOS lN10fUl NAlE Weight: 150lns SfOC,ke,': NO Ethnici ty/Correct ion: IlISPAIIIC 100,0% Oarometric Press: cnrs Correclion: /lormals: ;'1/'111) (,m I);",umllg 1 1,6 11111/1' ,11/1 11.1 Clinical Format: 1 [ASUREMErIT "IC (l) TV1 (l) 'EVl% IF25-75 (LIS) 'EF(lIS) IT (S) epo,·t SlIJTJlary: PIlUllIJ . 12: 2hPN Bnst Crite!,ia: !l!; T"i a I 1 C 4A9 .%Pl'cd 122 134 109 206 153 o 3.98 88 6,42 11.90 3.79 Pl'cd 3,67 2.96 81 3.10 7,77 SIII'I ill 2,69 2.29 71 re Med: Tests 3 Acceptable 2 Reproducible 0 rvc VAIl: 151Ml FEV1 VM: 329Hl PCF VN1: , 246HlIS IS Interpretation: PREMED -Norma I Spi rome try J!ll1lent: PREMED 14 "", .... ,""""""""""" .. ,· .. ·,' .. " .. ·"LEGEND' ~:"::"" .. :::::::::::::::::::::::::.C .... ·r:·md . . . . .. .. 8· .. : ... ', .. : .... : ......... : .... : .... : .... : .... : 6 1.\.... ,L .. :,;,:,L: ... : .. 4 ·:.,i.':-:..L. ..... t ... ? ... ; .... ~ .... : .... ~ .... ~ 2 ·,':, .. ·l·\.< ... L ... · .... L .. ,'.,.:', .• , ... . O~~~~~~-+~~~~ 012345678910 5 CM=lL VOLUME (LJ PREMED 1 3 2 B ......... , .. " ... ", ....... ";" .. ,,."" ........ , ................... : .... " .. , .... " .. , .......................... " " ......................... LEGEND' 7 ......... ~ ......... ~ ......... ~ ......... ~ ......... ~ ......... ~ ......... ; ........................... ~ ...................... _ ...................... -Pre : ::::::::j:::::::C:::::j:::.:::c::: •• !::: •••• /::::::::L::::: ::::::::.::::::!::.:::::: .:::: :.: •• :.: •• ::::::::. "', ~~Ed . . . . . .. . 4 ....... ·.:· .. ..' . 3 ... >:,; .. "::::1~: ::.'.::::--: :.:::'.: .:.:: ::: :::.::::: ::.:: r:::::: I::::: :::::: ::::::: :: :::::::!::::::::: ::::::::: .:::::::::::::::" ........ . 2 .' ...... " ........... " .. " .......... , .... " ......... " .. ,." .. " .. ," ....... , ......... " ... "., ........ , ........ " ....... , .... " .......... .. . ... . . . . . 1 ........ : ..................... , ..... : ............. . . . . . 0~--~---+----~--~---+----~--~---+----~--~·----+---~~~·----+---~ o 1 2 3 4 5 G 7 8 9 10 11 12 13 14 1 CM=lS TIME (S) Page 1 of 1 1 3 2, ~ OC.GUpationalllfediCine . , . T and Rehabilitation Spirometry Name'~4~J -Z4NO'~.4 Company t·· .. \. " ) Temperature Sex Xc..-._ M--: Height: . , Social Security No. F--/jy'l' ·-ys -":'>~19'Y Actual Value::~';e~diCted Value % of Predicted Value 4.<)9 . liters 2.4>7 liters , , ) Z .. :c '3. ?8 liters Z .. 0/4> : liters 13~ . .. . .F.VC FEV1 '!' FEV1/FVC 1'6 % (/ 75% RESPIRATOR CU:;ARANcE GUIDELINES I. mH'·TI"lrrJ:Hij,:+~t':I~":I::~I~ .. ;'fl;'fl:~.;m·11;IT-:fi·.~:.~~.~ ... ~.==~~---1_1Cl • • REOTn<onl'C .• • • • • • t1,,;.~!· r • ....llll 11"-1.:; I , • • ••• ~. r ~ • t ". • I... . I . . . I ..... ..~ I / -~ .' . r. I, • • • • ••••• I ••••• ': .... ".'..... \J IY 00 • • • • • ' • I • ! • I I I • '.'::!::, [~I 70 .:t:::~::::::::::::::::::~::::::::::fj':::::: , 1111 . .., . . .. ::::::::: .. :: .. : .... : • "" • • I •• , • " ••••• . .. ... . . . " ..... . ~ 50 • ,',".,' ',.' , , •.••• '. .' NON-N'?ROVED . . •. ',. ,'.' .. ,',.' .•••.•••.•. :W'l I] . . " .. .. . . . . .... . . ...... ...... : .... ' ... ~ ....... ~ • • -" " .'" . . •• ,ll;. • I •• " •••• I' I I I •• • .., I , I. '" • •• • • I • • •• • • • • I I.. •••• • • • ••• • • • • • •• • " I • •• I • • • • • ...., • I • I • , •• I" I • • • • I " • I I • • . " ," . . . . . ...... . . . . 'SiMJ!\?ttH • I II •• I I •••• ,. t. • • • ,. • t '" • • • • • ..,.,. , , • '" t,. ',,' I, : ........... :' • :. " '. " • ", •••• 'T." ,<01. 111 20 .•• ',. ' ... 'r ... ", :', ~ ,~. '. 1 • ',. '0,' I • .' • ' ••• I •••• , ' I ',. ~,."~ I, OOSTRIJcrll'lE"' ;' . , . . ',,:',.' , ' . . . . . . . . , ..... , " .... , , . . . • • ,',' .'" ., ••••••••• 'f. , •• , ok) .',',. '.,' ',I,' " ,", ", ••••••• " ! • '; .. t, •• I I, • , ••• I ,'. ',:',,",:',: i.','.'.· VEm~ ,., ... ,. · . , ',," . .".,".,' •.....•. ·1·VI·.;·.~.;:·I"I·"r' ..... . ~~utB~2off~oof±~~~·±.~w~~w~i~u~w~~crt~N~~O i~~ COMBINED fJ'C 1\ Cf f'IlEDm9) ~P0ved . o Not Approved EXAMINING PHY ICIAN / PR~VIDER. . :5 . I () L) J,W, Dunld~, MD ----'---=:..,....,'--1..--'-1. f-+-----tl1f)-Bfyant Street DATE Denver, colorado 8021 303:936 .. 9700 " OHS{912 I"';;, ( W®RKCARE'M ~"Maklng Health Count WORK STATUS REPORT Employer Copy TYPE OF EXAMINATION: Periodic Examination EMPLOYEE: Ibarra, Melissa ID: DATE OF EXAM: 01/24/2011 EXPIRATION DATE: 01/24/2012 COMPANY: POSITION: LOCATION: SITE: BELFOR Environmental, Inc. Asbestos Supervisor BELFOR-Denver 1 Denver The following recommendations are based on a review of one or all of the following: a base history questionnaire, supporting diagnostic tests, physical examination, and the essential functions of the position applied for or occupied by the Individual named above. Has the employee any detected medical conditions that would Increase hislher risk of material health impairment from occupational exposure In accordance wilh 29 CFR §1910.120? Does the employee have any limitations in the use of respirators in accordance with 29 CFR §1910.134? STATUS Yes D D No Undecided IKI D D 1. IKI QUALIFIED The examination Indicates no significant medical condition. Employee can be assigned any work consistent wilh skills and training. 2. D QUALIFIED -WITH LIMITATIONS The examination indicates that a medical condition currentiy exists that limits work assignments on the following basis: 3. D NOT QUALIFIED 4. D DEFERRED The examination Indicated that additional information Is necessary. The employee has been given the following instructions. COMMENTS: Examination in accordance with OSHA 1910.120, 1926.1101 (Asbestos Certification). I have reviewed the medical data of the above named employee, and informed the employee of the results of the medical examination and any medical conditions that require follow-up examination or treatment. Name of Physician: Peter P. Greaney, M.D. Date: 01/27/11 Signature: f.v:-! 9~ "" STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air Pollution Control Division This certifies that Melissa Ibarra-Rodriguez Certification No: 12150 met the requirements of 25-7-507, C.R.S. and Air Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Supervisor/Project Designer* 2/4/2011 Expires on: 2/412012 * This certificate is mUd Dilly wUh the possession of a current Dlvision-approved tmiuillg course certification ill the discipline specified abol'e. upe ',j, -Ramirez '~ ATION .. ~ ........ Environmental and Safety Training L.LC. 720 Billings street Unit F Aurora, Colorado 80011 . Phone # <nO) 8,59-3134 . Fax # (720r859~0660 Has successfully completed ¥:ti.~·'iftJ;~4~~~iROiVED· AHERA ANNUAL ASBESTOS REFRESHER COURSE for SUPERVisoR requirements examination in that discipline ;';~~~~'~~;~~?Zl6~ E:P A.-A1Ppr'ovl~ under Section 206 of the ~ 'l'!)jd~:Sub,stalllc.eControIAct (TSCA) . . .(02/28111 m1:I~iut:~'Si?'\' <8 . t0022811-01.ASR 02/28112 'this course meets the. requirements Of AQCC Reg: #8···· InstrUctor Name: Horacio Cuevas .• ., * 1< ~ I*~TEXAS Department of ~ State Health Services www.tdh.stafe,tx.lIs/beb/asbestos Jose Guadalupe Ramirez Applicant Name: (First. M,I., last) Physician's Written Statement Medical Surveillance for Asbestos Exposure Environmental & Sanitation Licensing Group 8001572-5548 or 512/834-6600 Fax: 512-834-6614 640-03-2469 03/27/1959 Social Security # Date of Birth 720-621-8502 Telephone Number (including area code) 3802 Rowlock Vine Dr. Houston Texas 77084 Street Address: -City State Zip INDICATE WIDCH ITEMS WERE PERFORMED WITH PHYSICIAN'S OR ASSISTANT'S INITIALS: (Any that are not applicable, must still be initialed off in addition to the NI A.) The above-named individual was seen on 08/17/2010 (Must be filled-in by Physician or clinic.) Completion and review of the standardized medical questionnaire and work history with special emphasis directed to the pulmonary, cardiovascular, and gastrointestinal systems per part I and 2 of Appendix Din 1926.1101. If employed, the employer provided, and review was made of, the employer's description of this employee's duties as they relate to the employee's exposure, the employee's representative or anticipated exposure level, the personal protective and respiratory equipment to be utilized by the employee, and infonnation from previous medical examinations of the affected employee that is not otherwise available to the physician, 6;i.( A physical examination with emphasiS upon the pulmonary, cardiovascular, and gastrointestinal systems. ~ The pulmonary function tests of forced vital capacity (FVC) and forced expiratory volume at one second (FEV I) in accordance with NIOSH and ATS standards, ~ Indicate whether or not the physician decided that an x.-ray was required and was performed: YES __ or NO ~ chest roentgenogram, posterior-anterior, 14" x 17" or current film on file with interpretation in accordance with 29 CFR 1926.1101, Appendix E. *NOTE: According to 29 CFR 1926.1101(M)(2)(ii)(C), the requirement for a chest x-ray is at the physician's discretion. ~he employee was hummed by the physician of the results of the exam and of any medical conditions that may result fi·om asbestos exposure including the increased risk of lung cancer attributable to the combined effect of smoking and ·asbestos exposure. Unless otherwise noted below, this evaluation indicates that no medical conditions were detected that would place the employee at an increased risk of material health impainllent from exposure to asbestos, and no limitations are recommended on the employee concerning the use of personal protective equipment or respirator. By signing this form, I acknowledge that tltis examination has been perfmmed in accordance with either 29 CFR 1926.1101 or40 CFR 763.122(a), as required. Comments or limitations, ifany ___________________________________ _ MARCO R. ESCOBAR MD 713 663-6322 Print Physician's Name Telephone Number (including area code) RE MED CARE CLINIC. 5420 BELLAIRE BLVD, SUITE A BELLAIRE TEXAS 77401 Street Address City State Zip PRIVACY NOTIFtCATION 1 NOTIFICACl6N SOBRE PRIVACIDAD With few exceptions, you have the right to request and be Informed about information that the State of Texas col/ecls about you. You are entitled to receive and review the Informat/on upon request. You also have the right to ask the state agency to correct any information that Is determined to be incorrect. See http://www.dshs.state.tx.uslformoreinformation on Privacy Notification. (Reference: Governor Code, Section 552.021. 552.023, 559,003 -"d 559.004) .,1 solo por unaS cuantas excepclones, usted Ilene el derecho de sol/eitar y de S8r Infarmada sabre la informad6n que ef Eslado de Texas reune sobre usled. A usted se Ie debe conceder el derecho de reclbir y revisar la Informacl6n al requerirla. Usted tamblen tiene el derecho de pedlr qua la agencla eslatal corrija cualquier informaci6n que sa ha determinado sea Incorrecta. DlriJase a mas Informacf6n sobre la Notificacl6n sobre prlvacldad, (Referencla: Government Code~secd6n 552,021, 552.023. Revised May 2008 Publication # F18-11669 INTERNATIONAl Environmental and Safety Training L.LC. 720 Billings street Unit F Aurora, Colorado 80011 Phone # (720) 859-3134 Fax # (720) 859-0660 ROBERT SALAZAR Has successfully completed The EPA-APPROVED AHERA ANNUAL ASBESTOS REFRESHER COURSE for SUPERVisoR And passed the requirements examination in that discipline This course is EPA-Approved under Section 206 of the Toxic Substance Control Act (TSCA) Course Date No. Hours Certificate No. 08/13/10 8 C0081310-06ASR 08/13/11 This course meets the requirements of AQCCReg.#8 ~4 Instructor Name: Horacio Cuevas • ASBESTOS PHYSICAL FORM I r L-______________________ ~~ I , Please check the appropri<lte ox: Complete A. 8, C as noted ~. Asbestos Physical j'VComplctc ~.B-,d C . Respimtor Physical D Complete A&B Only Do you con$j~our$dfjn good .health? '(!P No If not, Slate reason ______ ~ I I I, I ! I: i " I I' I I, I' I, ,I " I;'"~::;:" ~~~2~~/~"4::Z'//.~z...~--!~::::::::~· A=·~<:&k:.~·~:~·.,..;E~;I;~aminatio,~n~ ____________ ';;.,i Heicllt . ~ Weight Il.-'L--Pulmonary !'unction Test !I I Pulse "f.t2. BloOd Pressure I i Mil. rVC FEVI FEV/frEV II Rem/mtlon ,;;:-Lon.. Ac!ual _______ +-____ ~_% ' HNcartk ~ .Abdomen ~ Predicted ;/-7 Z' % '1 ec • -Nose . PIT comments I R~$Dim!or Medical Questionnaire comp!cted and reviewed YES N"O~~=================:j~ Ch¢sIX-R2.)'ftView X·RilyFilm#__ r X-Ray InlclpfCl31ion by; CRadlolo.gst OB R~udcr Other Laboratory Data /7l Specific Gravity, lOG: Blood: '-tr GIUCO~'loL-_ Protein: 4}':' o Corrected L 201 \c;-R ~ Uncorrected 201 \!':l Vision B 201 J?J A~bt;${oSlSMl)kjng Exp1an:lliol'l: tJ This employee has been ad .... ~d orthe results (lflhis e:mmil1rtllort : and hns been given an cxp1an41tiQn Qrmcdic31 con(1ilions thut muy 'tL"Sult from Asbestos c.'(POSlJre. and the incte<lStdtisk l)flung cancer nttriblJtabJc to the·combined ctlCclS ofsmok1ngand a."\Pc.~tQs e."p!J:,."m; Comments I ------------~~----~-----I! ---------.-~-~-~'.~.----------------------~,' D'dtCOf;;;::~ t.,h.?dr; 2 11' Signmure ofprovid'cr/f>hyslcian: c.-- " I I .. QUESTIONNAIRE FOR RESPIRATORY MEDICAL SURVEILLANCE I 1 This questionnaire is confidential and will be reviewed by Dr .. -._-;-;;;=-;,--;-:;-:;-;= ____ ~_,. If you I h!Jve any questions regarding this questionnaire you may reach the doctor at (303) 341-1799. I ; Print N~mc: Social Security # BIr1hd~te: Age: 1(D~~"\-~-( \ 7..J \ si t't'l1 "31 I el~1O Employer Job tille Oayphone: tM...~ .. &0 t~. 7!3r;.'i-5'~ ~'1 i 2>v'f"-'i v l;:' <:> f.- Height Weight ~ Female , Se~: : '$' \0 /I \(P 1 \\,~. , . Respirator Use QUestions 1. If you will be wearing a respirator, check which type of respirator you will use (you can check more than one) ON, R. or P disposable re$pir<>tor (Filter-maSk, non-cartrldge type only) OOther type (For example, h"lf f\JIl (<lce piece type, powered-aid, air-purifying, supplied-air SeBAl , , 2. 3. 4. Describe your work whiTe wearing" re$pir<>tor? ~ £b...\ Q I 0 ( s,i'~ \lop. \'\1\. Q,~ (Q!.\U~/Il.tt~ .\-iiI'\ C).~'%. \ I' . 5. . p I 6. List other protective equipment wom while using a respirator. .-"c!$.Ls.s;~...l..1,lll~~""'::~.J,j',.---"JcSL~+I: ~~~~~ . I 7. Describe temper",ture and humidity conditions when using a respirator. _..t.N1ts.:¥.lJ."""""",,,,,,,,,,,",Q~. _____ +i, I, Medical History Questions 1: Do you currently smoke tobacco, or have you smoked tobacco in the last month? ?. Have you ever had any of the following conditions: a. Seizures (Fits): b. Diabetes (suQar disease) c. Allergic reactions that interfere with breathing d.) Claustrophobia (Fear of closed-in places) e.) Trouble smelling odors 3. Have you ever had any of the followina conditions: a.) Asbestosis b.} Asthma c. Chronic bronchitis d. Emphysema e. Pneumonia f. Tuberculosis g. Silicosis h. Pneumothorax (collapsed lung) I.) Lun!:j cancer i.) Broken ribs k.) Chest injuries or suraeries L} Other lung problems you are aware of 4. Do you currently have al}Y of the following symptoms or pulmonary or tun!:! illness: • a.) Shortness of breath b.) Shortness of breath when walking fast on level ground or walking up a slight hili or Incline c.) Shortness or breath when walking with ether people at an ordinary pace on level ground YES : NOli I' I! v1L -l-- ....-(," /, --1, -4!5' --1--- JJ( ...r .. t« ;),f 1L Iii t1 W ~! k( 'ii v1I v }-,/ I . tV I if 1 d.) Need to slop for breath when walking at your own pace on level 9""TO:;:uo.:n.c:d'---__ -l __ t---':-7"-I e.) Shortness of breath when washing or dresslng'--__________ -+-_-+_::-7'f v Ii f.) Shortness of breath that Interferes with Job g.) Coughing that produces phle~un iJ.". h.) Coughing that wakes you early in the moming f. I. Coughing that occurs mostly when lying down .r j. Couahina up blood in the last month tV k.)Wheezing '!Y .. L) Wheezing that interferes with your job if' m.l Chest pain when YOU breathe deeply V n.) Any other symptoms you thing might be related to tung problems !I/' 5. Have you ever had any of the following cardiovascular or heart problems V a.) Hear attack IV:: b.) Stroke t c.) Angina IV d.) Heart failure V e.) Swelling in your legs or feel (not caused by walking) ~ f.) Heart arrhythmia V g.) HiOh blood pressure V h.) Any other heart problem you're aware of V 6. Have you ever had any of the following cardiovascular or heart symptoms y a.) Freqlient pain or tightness in your chest Iv" I' b. Pain or tightness in your chest durirl9 physical activity_ c. Pain or tightness in your chest that inte.rferes with your job d. Heart skippina or misslnQ a beat during the last 2 years e:) Heartburn or Indigestion that is not related to circulation or heart problems f. Other symptoms that might be related to circulation or heart problems 7. Do you currently take medication for any of the following problems a.) Breathing or lung problems b.) Heart problems c. Blood pressure d.) Seizures (fits) 8. If you've used a respirator. have you ever had a ny_ of the following problems: a. Eye irritation b. Skin allergies or rashes c. Anxiety d. General weakness or fatigue e. Any other problem that interferes with your use a respirator; 9. Might your job duties ever involve arc welding or coal handling. ·10. Would you like to talk to the doctor about your answers to questionnaire? QUESTIONS 11 THROUGH 16 MUST Be: ANSWe:RED BY ALL EMPLOYEES WHO HAVE SEEN SELECIED TO WEAR RESPIRATORS, WHICH HAVE A rUll FACE- PIECE (INCLUDING SCBA'S). FOR EMPLOYEES WHO HAVE BEEN SELEC'fED TO WEAR. OTHER TYPES OF RESPIRATORS, ANSWERING QUESTIONS 11-16 IS VOLUNTARY 11. Have you ever lost vision in either ey_eJtemporarily or permanently) 12. Do you currently have any of the following vision problems a.) Wear contact lenses b.) Wear glasses c.} Color blind d.} Any other eye or vision problems 13. Have YOU ever had an iniury to your ears, including a broken ear drum 14. Do you currently have any of the following hearing problems a.) Difficulty hearing b.) Wear a hearing aid c.} Any other hearing or ear problem 15. , Have you ever had a back injury 16. Do vou currently have any of the following musculoskeletal problems . ,., a. s in any of your arms, hands, legs or feet b:' Back pafn -' ~7" ........ t J/J,.,I} A IQ, QjffiGuity fully moving your arms find legs d,) Pain or stiffness when you lean forward or backward at the waist e.) Difficulty fully moving your hear up or down f. DifficultyJully movi~Juul'-Qead side to side g. Difficultybendipgyourknees ..-O"C-...... ~ /U. f V,~··\, , h. DifficultY., squa\l;M ""':t,tiEi ground v I. Difficulty climbIng stairs or a ladder carrying more than 25 pounds . Other muscle or skeletal problem that interferes, with respirator use: / V /' or I' ", V ./,"" ~ ,I •• '( Y .y V. V S IV l.f' if ty. .v, V, t/' . .' "i'l ..r,: 1 I· I: Ii I: v -?' V. 1/ -v f.' .. ~' U Ir-/ V if, V/ -r, y V j, / y, IV, V/ if 1 V- V tf( I 1 I· i~ I TOTAL P.008 Patient Name ~p\o~,{1. ~ ~n:cuf Asbestos/Smoking Explanation This employee has been advised of the results of this examination and has been given an explanation of medical conditions Ihat may result form Asbestos expOSUre, and the increased rj~k of lung cancer attributable to the combined effects of smoking tmd asbestos exposure. (In accordance 10 29 CFR 1910, 134) commen~. , 2? Dale of exam < .;;L.:l--?/iv ... PhYsiCian~. r I' I !: , , I I' I 1 I ,. I, " I' I r I ,. I' I' I I ! ! r " , I t !I .'./ I . . .. .., ..... .. ~. ~,,~.~ DATE 12/29/10 TIME 13:Jl BTPS 1.101 Ver 3.4 iIJI'I!>E Sa I aza r SIRTH DATE 12/15/71 AGE39.I£IGHT in 70 PREDICTED Knudson PRE FILE N" 222 <W: .. RobHt 1110 553130716 SEX <! WEIGHT Ib 162 PRED. C<XWERSJON 100% FLOW.-VOLUME 2, VOl(X.lE-TiME curves < +) flOW (Vs) TIME (s) . -~ ._-; . '--r" --T"-1'---r _H, T--' "'1 loi ..... H..;..... . t.HHHH ... j ......... ~ ....... ; ........ f ....... ~ Ii; i ~ ! i .r S I I .: : Ii! ... . T' ...... r ..... 1" .... "/" .... "/' .... T" .... ··f"' .... i , I , , , , I i J °i' ····· .. · .. i' ......... : ... """ : ........ ·t.: .......... ':'., " .... {" ........ ~ ! fl·} I i j' -'r~ 4J .. · .. · .. ( .. ·· .. 1 .... ' ...... 1·· ....... ( ......... ! ........ ··t· ...... ·~1 2 .... : ....... j ........... 1...:.: ..... L ....... ! ....... :.:/. ......... L ... I.Qi : I I : f i 1 6 · ...... · .. l: .. · .... ·+ ........ l ....... J .......... ~ ....... { ....... I (-) VOLUME (L) PREDICTED • . " " . /--. -,,_.-/oEASUREO PVC L 6.47 5.00 100 FEVI L 4.SS ~'4.19 100 PEF Vs 10.91 9.37 116 FEVl% % 83.7 82.6 101 ! .. _ ... ,_., '<--'-'-' . ..-.-,-.-.-.. -.,~ •..••. -.-~ .. '-.-,-,~,~,,-, ~TER PRE #2 PREDICTED' lCTEO FVC L 5.33 A:Vl L 4.65 ·FEV1% % 85.4 PEF Vs 10.91 FEF2575 Vs 5.40 FeF25% Vs 10.n FEF~ Vs 8.20 FEF75% Vs 1.94 .. FEV6 L 5.31 5.08 105 4. 19 109 82.$ 103 9.37 116 4.38 123 S.68 117 5.21 119 2.14 91 FEVVFEV6 % 85.7 FET s 6.19 VEXT mL 80 FIVe L FlYl L FIV1% % PIF Vs 5.08 ~ 4.19 ~\, 82.6 9.37 ._.-.. -,_._-...... Sf> l"\it·~lF'Y WiE'RI'RETI;lTlON --........... . •. ..i I I I • I I I. I Respirator Fitness Letter -Date: \-L\u\\O. , Dear Reader. This letter is to certify that ~4 ~ ~, or is not; lit to wwr a respirator during performance of daily job duties per OSHA 1910.134. This decision is after recent completion of a respirator review. 1. The p;tient Is: ~~~fit to wear nn air-puril')'ing respirator while performing current Job duties. 2. Medical Umitatioos or workplace conditions wllllndude: ________ _ 3. ;7 p;.~er medical evaluations are required at this time. ~Further medical evaluations arB needed at this time. those follow up evaluations are: 4. On /.:2--"/2="1'&(/ (datel.the patient and the employer were provided wittla written copy of this recommendation These results will rem"in confidential. and they v~II be kept on file in our office. (Signatu~o:::s::iC'~I<I!!<n)L-__ _ (printed~4 OccMed Colorodo, LLC 550 E Thomton Parkway. Suite 110 Thornton, CO 80229 OccMed Color>;ldo, LLC 3449 Chambers Road, Suite B Auroro, CO 80011 I l, I' I I, I, I, i I, I, I I I, I' Environmental Safety, Inc. , Awardsfo Andre Williams This, Certificate of Achievement In ' 8 Hour AHERA Asbestos Supervisor Refresher Course This course is EPA approved under TSCA Title II & Colorado AQCC Regulation No.8 , October 2, 2010 October 2, 2011 10-626 , Course Completed Expiration Date I D # ~ M =CD,I"i),r\),o;,WK.. David Ryan,' Instructor/State ID # PO Box 460246 Aurora, CO 80046-0246 Phone: 303-340-4315 900 . d 'IV J.O.L ( PHYSICIAN'S WRITTEN OPINION -ASBESTOS ~ f ( .---~// Applicant's Name: L.APlc{--e L-I..//( r/a.", ,L Address: 3'7$ 3' ;)' k~'I(c<v?t~-y M(&,,'oJ/'q G <tOOIL The above named was seen by me.on , and in accordanw with all applicable portions of OSHA's Asbestos Standard tor the Constructionlndus!ry, 29 CFR 1926.110 I, with which J HHl familiar, I have indicated by my initials, that I have porformed the following. 1. ~ Reviewed with th'is individual, his/hcr completed OSHA standardi;ccd Medical Questionnaire and Work History, directed towards the pulmonary, cardiovascular, Hnd gustroiutcs\inal, system; and 2. 3. 5. 6. 7. 8'''=l-- Reviewed the employer's description of this illdividual's dulies as they relate to asbestos exposure, the anticipated exposure lewl, the perSonal protective aud respiratory equipm~nt to be utilized by the individual; and any additional medical information resulting [rom previous examinations; and Conducted n physical examination of this individunnvith empha~is on the pulmonary, cardiovascular, and gastroint~stinal systems, including a pulmonary function test of to reed vital wpacity (PVC) and forced expiratory volume at one second (FEV-l) and Determined that a chest roentgenogram was quired as a part of this examination. (If required, the x-ray was taken and read in accor)1;;;=-m;'ffi"Ahppendix E of the Asbestos Standard); and Determined that this individu~fi?may not _ use a respiratory device while perrorming his/her required employment services; Informed this individual that I have ave no' detected a medical condition which would place this individual at an increased risk of mater lealth impairment from exposure to ashestos; and Informed this individual ofthc rcslllL~ of my examination and or any medical condilion that may result from this individual's expOSllTC to asbestos; and Informcd this Individual of the health risks involved in smoking, of the synergistic relationship between cigarette smoking and asb~stos exposure in producing lung cancer, and that c~ssation of smoking will reduce the risk of lllng cancer. . Comments and/or Limitations (if any): ~\ W\W\\ E _ 't<clIK (Physician'S Printed Name) l ~O e,> '?sSC; ~ & 13 1 ~~~~~;i~~ .... W -./<7 tl ~L"'L-C-----"-- 3449 Chambers Rd., Ste, B Aurora, Co 80011 Ph: 720-859-6139 Fax: 720.85!)"3294 (Physician's Phone No.) (Physician's Address) QOO·...:I'- .~ OccMedl 'llioraCJOtl( l)W.Jp:JfioonJ Ar.'d!(Jnt/ I.!fnl MUHUloJkl.,utl c~~ Date: 10 -6 ~ /0 Dear Reader: 5,'\0 C. Jlwmll1l\ l'urhw!.lY :;ull~ I JO' lhmntnn. CO 11022.1) [ This letter is to (!ertify that 0 -'I~l .. ,e' U/I's '"~, (" is, or is no!, fit to wear a respirator during perfonnance of daily job duties per OSHA 1910.134, This decision is after recent completion of a respirator review, 1. The patient is: ~ Fit I CUnnI to wear (m air-purifYing respirator while perfonning. , (!urrent job duties, : ' , 2. Medical limitations or workplace conditions will include: _.!.f../~tP.!.N.:..fZbi·::;"' _______ _ 3. )f No further medical evaluations are required at this time. 3. o Further medical evaluations are needed at this time, those follow up evaluations are: / / (date), the patient and the employer were provided with a written copy of this recorrunendation. These results will remain confide ial, and they will be kept on file in our office, f; -, ..... : . ,-'. . (Signature €'. J<-e./ gz (Date) (Printed name and address of Physician) 90: 9r OWZ-80-J,QO P.E.§ LLC RESPIRATORY FIT·TEST ACKKNOWLEDGEMENT Employee's NamSW\Z-\~\'-\-.\\AV\'i; Fit Test Date\\'H5' f)s.)\Q Person Conducting Fit Test-\Q\S'[ (~0~'0,\x\,:) Respirator Selected for Test \)D'\J\\... ~o....,\:'\\0~ /r;;... ~\l-...<:"Z , Manufacturer \~Q\-\"'. Respirator Size \~ \\)1/\ . Type of Agent Used "bQ-.~~\.\\A. O\L --).......-.--\ 0.' \-.. .\ ,'-Signature of Person Performing Fit Test 0 ~ ,-,\I.J~,'K:$~,,'0 '" l I have been fitted with correct size and model of respirator that I will be using in the performance of my duties at Personnel Environmental Solutions LLC. A respiratory -fit test has been performed and I have satisfactorily passed the irritant smoke test. Your signatUre on this Respirator Training record will attest to your having received and understood the following respirator training information which both OSHA and Personnel Environmental Solutions LLC require as a part of the Respirator protection training program Employee's Signature 0---4 L'~~-' -Date 10-/5-/ c; Personnel Environmental Solutions LLC '720.253,2927 Appendix E Waste Manifests Appendix F S&R Consultant Daily Logs 5801 logan St Suite 200 Denver CO 80216 Consultant Daily Log 303-297-1645 : Ii Project NameNe'S~A -'-/ tf -1,/ 1.;"')5 Date: "3 -/ s -/ ( , Project Number_-=()..:.!I.:...'/-=o.:..::2=-::6~ __ _ Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: I r.2 .2 '00 3//&/(1, Cree; . $ / Ie.. &/ ere "'-v ([ ~(),C 1. ",-Ceq s , Time: {., II J v Time: I (e..-. 6 Time: 0,./"1 Time: Time: consu,tant:_.f-71-w-/""eL.-'X"--_6_'-,-f'e..:=.o.€A,,,-,-__ e. OA ..( I i-e- ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 I lJI-{th fJ I --J Project Name. / V YC) ) Date:? -"'/6--/ / ./ j Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: him.: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: G!(,C ) Consultant Daily Log Project Number 0 ( 102.6 5801 Logan St Suite 200 Denver CO 80216 303·297·1645 --If, . Project Name. '1 F t tvf»i/ 5 Date: 3'-/6-/ / Consultant Daily Log Project NumberCJ((OU ({ •. ~Y.2,~IVO 111)'111/~:r~ ~ d" ' Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: c:; / S· ) ) 5801 logan St Suite 200 Denver CO 80216 i' 303-297-1645 il Project Name.--il{Lf.-.-fI_!;.,.._.l---/-t----"t-".v..:J.q~j:.L· --:-i~'--- Date: i_I 2_" / / I -J ./' i . Time: '7.0C' " Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project Number ________ _ Time: ) Time: J~ '. r -I I .. . fb,..,<--{IC b' n /er fl I p Time: TIme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: • (V Time: Time: Consultant:--'\:(;;;.""I',J.p'-'-S'--_____ _ . 911 ) 5801 logan St Suite 200 Denver CO 80216 303·297·1645 i 111 ,';\./ I d ____ '1, ~A /" (- ProjectName. if t V q ) Date: 3 ~ J 7 -II Time: ,{-' Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ilme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: __________ _ Consultant Daily Log Project Number _________ _ ;:. 0 /.. -f:, I J1 IVl e 111 c 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Consultant Daily Log I "I d.i Project Name. ''I AI ± tV" ,":5 'v ,,' T I? "-'''" Project Number 0 j I 6 d (,., Date: ,'--I 9" f I Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: lrime: Time: Time: Time: Time: Time: Time: Time: Time: Time: Dme: Time: Time: Time: Time: 010<> Ii o 600 Consultant:~q-+-'_~'--_______ _ I I q .::'..,(, ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 dl I Project Name, /,1 d -r DU ", . .015' u· c·,~ T t.. Date: 3"~ I 8· i I Time: Time' Time: Time: Time: Time: Time: Time: rime: Time Time: Time: Time: Time: Time: Time: Time: Time: 1\00 1/ os ~ HQS ..-I.;} 10 [~+ "toll{ k c< c k r: )«' c cZ V C1 ~l e r- -tic? 1/\/) VA81(? k Consultant Daily Log j "~ t? 1:':.(4<1/ Project Number 0 I I 0 ~'l ? , >:1 j v{~, i-\ I , (\ <::~ -.... j=·"c,-; 1/, i,.:.." t~ 0 (--. 0<" 7 V"1' 0'. I) I I I-f..j (1 r k 3 I , Time: "lime: i __ ~O'-<.f"-",~",..o(,,,7,,", L) -..2,,~, (1-"-<"-'l.!"~~""""'--_t!2g>--i:'·-'-?~;Ui"'--r1 ~''\l'''<''-J'L) iY",b_,(L"J,I",cf""S.-_ ,,·f Iv" (!wjJl ; ., r "f" ' 4,!2 ' _._-_._-£ r ",It € q :i T" e "'-{( . ,;:::. X <:!if (3 -f '" b c _ ;I 0" VI <~ ")~! U , "Po 'U « .I.! c { <...-~ <.1 '-\. \ -" ",",1/ Time: Time: Time: consu'tant:' __ ·.J.g-i---'K~ _____ ~ 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. -'I i cfj + LU c.)? 'v H'-;--R" ,) ev Date: 3 I l? I \ Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: consultant'_-'-1+-' -'!<-" _______ _ Consultant Dailv Log " r Project Number 0 I ( 0 d L • 7 I't,f/lf::>i 1~ -y NOM 5801 Logan St Suite 200 Denver CO 80216 303·297·1645 Project NameH1l ~ It,;, is I Date: r -2. f -/I Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: f) ,'I A Time: ~_v Time: Time: Time: Time: Time: Time: Time: Time: r.. WL Consultant: ,#..X Consultant Daily Log Project Number C) II 0.2. 6' ) J: 15 -!111lJt-&cl. ~~ ~/l\.;. ,A of-LJ / a ~ -DI'tJ f' 0 ~ -tvl..: r M.(A f· S ; Jo -Ltifrl-Sf h.... 5801 logan St Suite 200 Denver CO 80216 303-297-1645 0 LI tl-~ ( Project Name._:J .... J-'-_-'-, -"w""A,,-,cI-=-s ".....,4"". ~,-,-rk-=-. __ _ Date: '7, /z lltb 11 ri Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: 12: ID " 1/ Consultant:'--rDAt.\ GOl)? ) Consultant Daily Log Project Number----=O_J:uI..::D...::Z"", ~,,-'. ____ _ #. I~L114 5801 logan St Suite 200 Denver CO 80216 303-297-1645 i.i Project Name. ~ 1 e/!vq J. s oate:-J--2.!2. -1/ TIl 7,(90 CPT Time: Time: Time: Time: Time: Time: Time: Time: Time: Time ~ZJ 0 Time: \ Time: Time: Time: Z<s Time: Time: Time: Time: Time: Time: Time: Time; Time: Time: Time: Time: consultant:...J6 ... '1I1.KlId'L' ... 6'--____ _ Consultant Dailv Log Project Number (]) II () ~ 6 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. q l(~~/L.;CiJJ I Date: "1 -2. J.. -I / Consultant Daily Log Project Number 01/02. <:; Time. Time: 12:55>-.r:.rrrve.,c .~sde.. foLL dl-d It£+ 'Sif<..--fr:, /"e-e 6CU .. f.- Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: TIme: Time: Time: Time: Time: Time: Time: Time: Consultant: AI et. G re,e.A ) ) 5801 logan St Suite 200 Denver CO 80216 ~ 303.~97'1845 <II b J 'J PrOject Name, a ,~i OS. Date: g IZz.I'/1-1Ji r l Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Ti01e: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project Number () !/{JtftJ 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. 41·H/l..! «-}; Date:S'!D/II J , ; Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time; -, I Time: Cr-w «I +1 , Time: /1 ~ {O~ C 1(;<,> ~ r t I .n Consultant: ;fte,& G! teet' 0 Consultant Daily Log Project Number_-"(l=--..:II_o_2.---.::£'--__ _ 5801 logan 5t Suite 200 Denver CO 80216 303·297·1645 Project Name. 1f1 j.], / L..;"J j I Date: ] <2. :> -I { Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: I: Consultant: II=! ex t:; r-e~ ) 'Ii r SVi'" f(eJ. ;'"fc, d1e doOs Consultant Daily Log Project Number_o::...:...II'-0=-7..-.:6=-___ _ (lo·n CrewJ tJo,). (j oJ zk. 5801 logan St Suite 200 Denver CO 80216 303·297·1645 h.f!. Project Name. 1 r 1 /tvq d \ Date: ') ~ ~3-I ) 1 Time: b Time: Time: Time: Time: t-..':f Time: Time: Time: Time: Time: r I Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: __________ _ ) Consultant Daily Log ·ft I j 5801 logan St Suite 200 Denver CO 80216 303-297-1645 t I Project Name._fI1!-'---I"'i",---£"lJ,---~:=,;:s,---_____ _ Date: ~/l-tfj(1 Time: Time: Time: TIme: Time: Time: Time: 1~ Time: Time: Time: Time: Time: l 'lime: Time: Time: Time: Time: Time: Time: Time: [[me: Time: rime: Time: Time: Time: Time: Consultant:--.!..\-L..'><-=--'---.::::..:::-'--__ ) Consultant Daily Log Project Number (} 1(02. 6 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. 4,\ t L!l.J 4-.( Date: S IJ.. 4/ t/ i Time: Time: Time: '0 " Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consullant_----'Ilt...l.:-e..K.='---'C=-:H:..-c..:::::-,OtA=-__ Consultant Daily Log Project Number __ O--,-''--' 0"---2..-=-=6 ___ _ 7 I 5801 logan St Suite 200 Denver CO 80216 303~297~1645 ~ l ii- Project Name. t 1 r he .... .1 i f ,I i Date: ~~ cN'/-I! Time: Time: TIme: Time: Time: Time: Time: Time: Time: Time: Time: Time: )nme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: r H<;' Consultant:....Ib~,:·-'-'-;-~~.L) _______ _ Consultant Daily Log Project Number 0 If alb ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. l../ t--r!2 't' G.'''i d f ~ r, Date: -.2, r~1! Time: f Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant. __________ _ Consultant Daily Log Project Number (] (I 0 :L 6 ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 Project Name. £,./ til;" i kaZr0 oate:j ~~ l-IJ Time, C: '5 Time: TIme: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Dailv Log Project Number C) Ii f) 2. ); Time: Time: -+..--I--.-L-~0f-A~~--:'i,('++-f-+.-'<'+D--'l---J;l'7LLLL4L-I-~--f-":;'--,~t--L!l;L-'f"'--J-H~.!1f'-~ h~-r/ Time: Time: -4~~~~~~~~~~~~~~-=~~~~ht~L~ftl Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant:_--\9-1'---______ _ 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 . ,,11 ft . .1 Project Name#.-,k-/,-Ir-,-~~1f--h-,,-i..::..,Q'{f---".q-d5'---_ 'J • i I II Date: 1-2 ;.--. .r . I Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: \ . IfIme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: lime: Time: Consultant: ___________ _ ! Consultant Daily Log Project Number (:J 1/ () 2. k ) 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 11 1. Project Name. t·e/-··J-r rvcr cl s Date: 1-~e; -II Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project Number 0 il 0 ~ b r . I Time: 3, 1 5 G ,PS Off!If e Time: Time: Time: Time: consultant:_C--+-t'----'--s ____ _ ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 ~ Project Name. 411 1.t: LL./I{/S V I Date: 3 :roll/ ~ J Time: Time: Time: 7; ;L.0- Time: S 6 bA Time: Time: Time: Time: Time: ''I: 00 - Time: Consultant Daily Log f j I () ~ Project Number 0 lie; 2 6 Time: -.!..1 ~ --,LJ--=O,---...<.L~""""'_-'-"''_'_'_'''___...J.Ul-''>LLL..<:.~___'=:..L~.L....,_'+'''-''''CL....~F'''''''-c--'-+'''-'.J=<''-'-I-- Time: )rime: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant:---1...j...:.l.L.:::..---"'----'-="'-'-__ _ ), 5801 logan St Suite 200 Denver CO 80216 303·297·1645 /, /, Project Name. if 'I f 'L W"b Date: 3/7, 0 III ~ ; Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: consultant:-t-If1"H-g~,7'I(,--,c'=<'ec0,""",,=-___ _ ) Consultant Daily Log f j 2 .f Project Number 0//0.2,.6 5801 logan SI Suite 200 Denver CO 80216 Consultant Dailv Log 303-297-1645 -L-/!:iL r Project Name __ o/,,--f ___ t'_y_ j(0L-""-!~j,---__ Project Number C? It (/ :L6 Date:j-lC? -,I ) Tirr1.lJ 6t ~ '],9 "'/$ Time: /() Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: _______ _ ) Ad wrh 4/t¥ ~p AlAe! tJ;0t2~-t • 5801 Logan St Suite 200 Denver CO 80216 303·297·1645 iJJ. Project Name. "I 't f' hA ci ( Date: 1~il-11 Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project Number <9 //0 ~ 6 ) 5801 logan 8t Suite 200 Denver CO 80216 303-297-1645 W::!J-' 1._ Project Name,L.L t I/vqdf oate:--l:=3t-4_ Time ~/ )0 }c( Time: ----~A/f TIme: TIme: TIme: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: TIme: Time: Time: "rime: Time: Time: Time: Time: Time: Time: Consultant: _________ _ Consultant Daily Log Project NumberO II 0 </b 5801 logan St Suite 200 Denver CO 80216 303-297-1645 l; ?/ tJ, 7 t project Name._-I-.c...-_-=----.:. __ r.:....::J l/Io;L."cl!.Lc5~_ Date: i~ /--1 I i / Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ,Time: )Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project NumberO II (1 ~ 1Y ) 5801 logan St Suite 200 Denver CO 80216 303·297·1645 It Project Name. Y 't ~~ W'" ).1 Date: 1-(/ b/ It J Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: q. Ss -(' ~ eu/ • , Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time· ) Consultant Daily Log Project Number_-,O-=,.:..( "-0"-2-.'-'6 ____ _ u,o z6 . (f . Vl- 5801 logan SI Suite 200 Denver CO 80216 303-297-1645 t, L[tl L.l Projec,t Name-f 7 Date:!j ~ O/'~. 7 r{ rime: o Time: Time: Time: Time: Time: Time: Time: TIme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Consultant Daily Log lVCled j Project Number 0 I ( o~h 5801 Logan St Suite 200 Denver CO 80216 303·297·1645 f-)t/tJ-q' tVn (15 Project Name. I I I ." Date: t;:. 7-II i Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: 1, 'i c) c ~ llec pe J 'l('e(~ Time: Time: Time: Time: Time: Time: Time: Time: Time: T9 consultant:----"bd..,· .L!_~~'(L· _____ _ ) Consultant Daily Log Project Number (') /1 C? 1 b 5801 logan St Suite 200 Denver CO 80216 303-297-1645 {tlf·f i-I J Project Name. .,' 7 Vl/ ''! (~j Date:l /--5 ~ll Time: -;, 'f? t_' " .] Time:,~ I, } 0 Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: TIme: Time: Time: Time: Time: Time: Time: Time: Time: ~)'\ 51 be fi(';(i, '/ . " {}iJCJ r. I', 0 ! I ' ! Consultant Daily Log Project Number 0 I I () L), 01.( u" () {" C) 7 I ' Time: __ ~~+-~&&~~~~~~~~~~~~~~~~~~~~~LU~~~~~'O J, , :f () ;-~.I!(Yc ic I 1"" (> 0 '}-. /J'Pr' <M q I ft n~P Time: Time: ./1 - Time: Time: /' /J ", Consultant:""""",,,, . .,t.,Gc......L. _______ _ 5801 Logan 8t Suite 200 Denver CO 80216 303·297·1645 . f!. I I-L J.':I (2/ [ Project Name. I I (! 1/(:/15 Date: L( t ',' )/ ' I ' Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: TIme: Time: ) Time: Time: Time: Time: 'Time: Time: Time: Time: Time: Time: Time: Time: Time: 5" ir, ~>, '0 0 , J () Ie /) f I . '.,r) ('/ Consultant Daily Log Project Number 0 I/O),}) I Time: n () W---e Time 3'.2:0 -Puxvi'lo ~ D\O flte. 0l!l1'\5 t;)lre IAV\ 'oo.,a ("j Consultant: 13d~'S ~ ~\':::I.wo{\(\ ~. ) I" ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 I--';/:l,. W Project Name. 1-1 Y r f ,JS Date: Lj~7-Z I . Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: I Consultanl: _______ _ Consultant Daily Log Project NumberCl ti () L b ) 5801 logan 8t Suite 200 Denver CO 80216 303·297·1645 / Project Name. Lt Lj of h ~ We!), \ Date: L{-7-/ I Consultant Daily Log Project Number Q IL 0 ).. 6 Time: .L!lw7 .~' O~o~!..£!...-=--..!...J~L...~c..L........l2..!.._...!....:oc!'...!:b.-'----'~:.:I.,,!.L.'.~'--'-___________ _ Time: Time: Time: LJ Time: LJ1" Time: -0. 02.'-1, Time: J..12:!:::·:.,c:4..2.....:::.......",!,~4t-l:Ja~~_~:....C..:!.L.L5!......L----'ol:S..!..L~"'--l::Ja.l.!LL=..:r::.~~e::...,,~-":.2 ___ _ Time: q ('-e.....or . Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Timfij: Tim~: Time: Time: Consultant: /11<v< C; ~ " Consultant Daily Log Project Number C2 tC 0 ~./6 Time: IhtG. Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) 'Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant:----<b...L!...P--'JL-_____ _ ) ) Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: _______ _ Consultant Daily Log 5801 logan St Suite 200 Denver CO 80216 :~~:~:6~5ame.--,~~v{-ib __ 1t,,--. &:t=..L=u.d.<..-;:JSe--_ Date: ~~ vl---lL Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: TIme: Time: Time: Time: Time: Time: Time: .,..... ..-,..- Time: ~ "'- Time: Time: Consultant: ({",¢'" '("" --'" Consultant Daily Log Project Number C) L I () ~ 1J t;., i ) Time: Time: Time: Time: TIme: Time: Time: Time: Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: _______ _ ) Consultant Daily Log Project Numbe~ t( 0 ~ ~ 0" n J I! I n 'rr..ercb <, rAIh} ) 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 ,L/ 1--111 r I J Project Name. L p ,t--y tJj (L S' Date: 0--1':;: --// ,-/ <' //0 Time: ) &, Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Trme: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant:: ________ _ ) Consultant Daily Log Project Number ('IIi 0 2. h· Consultant Daily Log Project Number 0/102 6 Date:_-'of-'--=--''---'--'--_ Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: TIme: Time: Time: Time: I:~" -;{, ,,,,,,/If-0 fCc ic.< to J-fMl L4rft, .f.(\<· .... 15Jq e.-. Af-e.K ,) llif "-'flIte-. z , " " J---. l)" c Jv .. I' J F('Q f'1 0.,11. I '.h_'; 'rCDA Consultant:_-----<f<L.!.:"~"'·7--"'_..::v."_'_'~"'v='_'_ __ _ I ) ) 5801 logan St Suite 200 Denver CO 80216 303·297-1645 Project Name.,--JLj,--i-l'-ih .. f.---,,~----,Iy,-q","-· .... d'--.JI-__ Date: 1-/ r -! I Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ~ 0 / Consultant: f, I" 5 Consultant Daily Log Project Number (:J tL 0 ~1; Consultant Dailv Log Project Number 011 0 ~b Time: Time: Time: Time: Time: Time: . ______________________ _ ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time:. Time: Time: Consultant: ______ _ 5801 Logan 5t Suite 200 Denver CO 80216 303-297-1645 tj U~ -/ ~ ~ d Project Name. I h j/ 'i S Date:i-/1~1/ Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )rime: Time: " O(J Consultant Daily Log Project NumbeO!{ ()~, -6 Time: ::'~--""'-''---f-'I.4-''''-\L~~ ~-I-~~'2...£1,£::f---=,---::..r~'--f.,....::c;L----<;.~ ..... ,,¥-~~~~~ctL&f-:.,-t{)4- Time: Time: Time: Time: Time: Time: Time: Time: Time: ItlOO I Time: Time: Time: Consultant: __________ _ ) -.. _, .1 .. 5801 logan St Suite 200 Denver CO 80216 j I J 303-297-1645 [/ :J!l-~ 14 Date:,+-++",-++ __ Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: \ime: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant:: __________ _ Consultant Daily Log Project NumberV/tO ~ ) 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 " ! t-"j-/, projectl~me, 1 1 .c".)' t Date: ;1-,If-II '" ' Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant Daily Log Project Number (') / I C) ) l'l <:.cti Ie Time: ('l 1r.:.)(O 2_ c t ~'""" Time: 4,'7 d~e ~/ /12/1/ II, J Consultant: __________ _ ) / 5801 Logan St Suite 200 Denver CO 80216 303-297-1645 • / ? f. LN, /.1J1 '¢J 1 A,/ ») <)' Project Name .. _0_'--,1"'-,°_' _-_. ...;b=----J!---+L_'_-I<{:._""l'-J'-''''-'-Ettt Date: rrI) ..... 17 j i Time: Time: Ifl;r/IJ E 11'1 S () lit, ON)' () )" l' HK ( SA e,l '/(1 ' Time: (~ Consultant Daily Log Project Numbe/J ( ( 0 J, 6 ''V Time: ~~---f~~~~L-~~-L~~---}~~~~~~~~--~~f-~--~------~--------------~-, Time: Time: Time: Time: Time: Time: Time: Time: )Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant: ___________ _ ) 5801 logan St Suite 200 Denver CO 80216 Project Name._---"L'-'---t ____ 1'--~--_-_h_IG---,-,-"Oc.,51--__ 303-297-1645 (~~_::U_ / Date: L!~_! %"' J I P 'Ij G~' ~ $ ~f . . Time: Time: Time: Time: Time: Time: ..-y"-' ,'0 0 Time: /'i> 7" 1 a Consultant Daily Log () -) 6 Project Number I / .zb Time q>,()O G if ~ Drr tJ{ / <1 0' <j J r AI -r I Time: Time: Time: Time: ) Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: ~tJl h, 'f <'"cf tv ..---- ,- ConsuItant: __________ _ ) 5801 logan St Suite 200 Denver CO 80216 303-297-1645 'Ie iJ-~ if Project .Name. t( 7 't q I Date: lj_ ! l' ! Time: -), 15 hlr tJt1 5 de ' Time: TIme: Time: Time: TIme: Time: Time: Consultant Daily Log Project Number(") /I t7 ~ 6 Time: -',,::'V.!:;'"\..::.:.....,,,?!...,-J6<!LL--'-----;~L-_I_;'I___"H''---'CL-'-...L__'=i'_t'lL,LL~+_-d__''"'--l..J£;l./_;;....,LL~-------- Time: Time: Time: ,)Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Time: Consultant.: ___________ _ c'P t1 fer I 'q v'I.ere/: Appendix G HWS Environmental Inspection Report Solutions Through Service January 11,2008 Mr. Patrick Goff Deputy City Manager Wheat Ridge Urban Renewal 7500 West 29th Avenue Wheat Ridge, CO 80033 in care of Ms. Denise Balkas, A.I.C.P. Director of Real Estate Development Wheat Ridge 2020 P.O. Box 1268 Wheat Ridge, CO 80034-1258 Reference: 7340 West 44th Avenue, Wheat Ridge, CO -Inspection Dear Mr. Goff; HWS Consulting Group 7951 East Maplewood Ave., Suite 122 Greenwood Village, CO 80111-4724 303.771.6868 • Fax: 303.741.6745 www.hws.com Enclosed is the Inspection Report for the above referenced location. The following materials were determined to contain greater than 1 % asbestos, and are therefore considered to be asbestos containing materials (ACM): Non-Friable ACM • Floor tile and associated mastic, throughout entire building. • Wallboard joint compound, throughout entire building. • CMU wall patch on the east side of the building exterior. • Light ballast wiring is assumed to be asbestos containing throughout the entire building. Friable ACM • Fire doors are assumed to be asbestos containing throughout the entire building. • Acoustic ceiling texture and associated overspray on two interior soffits. No lead based paint was identified at the facility. No mercury containing switches were identified. No CMU fill insulation (vermiculite) was identified. No PCB-free lamp ballasts were identified. No mercury-free fluorescent tubes were identified. Denver Manhattan Lincoln Omaha Ames ... and anywhere else our Clients need us. Regulations allow the asbestos containing wallboard system and roofing (roofing is assumed to be ACM) to be left in place for demolition, as well as the floor tile and mastic, however HWS recommends removal of the floor tile prior to demolition in order to eliminate the possibility of contaminating the soil with floor tile debris during demolition, which would then necessitate a soil removal project, which is very costly. Further, if the floor tile mastic were also abated, the concrete pad would be available for recycling. Assuming the entire building is vacant and empty, and no additional items (such as additional asbestos covered electrical wire) are encountered, the following removal estimates would apply: $ 20,000 Acoustic ceiling texture and overspray, E side $ 13,000 Acoustic ceiling texture and overspray, W side $ 6,000 Lamp ballasts and fluorescent tubes $100,000 Floor tile, with the mastic left in place $ 60,000 Removal of floor tile mastic $ 500 Block filler patch Fire doors which are proven to contain asbestos would cost $100 each for disposal. This works out to an estimated $200,000 (± 20%) and approximately 30 work days to perform all removal items at current prices. We estimate professional consulting services for this project to be $20,000-$25,000; which would include project design, bidding, site visits, air monitoring and clearance services, and laboratory costs. Thank you for the opportunity to perform these services for you. Please advise us when we may be of further service. Respectfully submitted, HWS CONSULTING GROUP INC. ~o£Y~ Senior Project Manager 73-68-8401 REPORT ON THE INSPECTION FOR ASBESTOS CONTAINING MATERIAL AND LEAD BASED PAINT AT Antique Mall 7340 West 44th Avenue Wheat Ridge, CO 80033 FOR Mr. Patrick Goff Deputy City Manager Wheat Ridge Urban Renewal 7500 West 29th Avenue Wheat Ridge, CO 80033 in care of Ms. Denise Balkas, A.I.C.P. Director of Real Estate Development Wheat Ridge 2020 P.O. Box 1268 Wheat Ridge, CO 80034-1258 HWS Project No. 73-68-8401 January 11, 2008 TABLE OF CONTENTS 1.01 PURPOSE OF INSPECTION AND TESTING 1.02 DATE OF INSPECTION AND TESTING 1.03 LOCATION OF INSPECTION AND TESTING 1.04 HWS REPRESENTATIVES 1.05 CLIENT REPRESENTATIVES CONTACTED 1.06 PRE-INSPECTION REPORT AND EXCLUSION STATEMENTS 1.07 SAMPLING RATIONALE/INSPECTION METHODOLOGY 1.08 FINDINGS/RECOMMENDATIONS ATTACHMENT #1 ATTACHMENT #2 ATTACHMENT #3 ATTACHMENT #4 ATTACHMENT #5 ATTACHMENTS EP A AND CDPHE INSPECTOR ACCREDITATIONS ASBESTOS BULK SAMPLING SUMMARY TABLE AND SAMPLING LOCATIONS DRAWING ASBESTOS LABORATORY ANALYSIS REPORT ASBESTOS LABORATORY ACCREDITATIONS ASBESTOS LOCATION DRAWING REPORT ON THE INSPECTION FOR ASBESTOS CONTAINING MATERIAL AND LEAD BASED PAINT 1.01 PURPOSE OF INSPECTION AND TESTING Identification and quantification of asbestos containing materials (ACM) and lead based paint (LBP). 1.02 DATE OF INSPECTION AND TESTING December 19,26 and 28,2007; and January 11, 2008. 1.03 LOCATION OF INSPECTION AND TESTING Antique Mall 7340 West 44th Avenue Wheat Ridge, CO 80033 1.04 HWS REPRESENTATIVES U.S. Environmental Protection Agency (EPA) and Colorado Department of Public Health and Environment (CDPHE) accredited Building Inspectors Mr. John Gaddis, Mr. Landon Mood nd Mr. Benjamin Tuthill. Signature_--"~-+-__ ~_-n-______ _ Signature~~=..;::::......::.....;,..L._-'--_--""~ _____ _ Signature-==-->-..,;:;,-"),--~_--,,-,,-",,,,",-,---'r-""""""';"-__ _ cJ Reference Attachment #1 for EPA an DPHE Inspector Accreditations 1.05 CLIENT REPRESENTATIVE CONTACTED Ms. Denise Balkas, Wheat Ridge 2020 Mr. Mel Karl, Building Owner 1.06 PRE-INSPECTION REPORT, EXCLUSION STATEMENTS AND ASSUMPTIONS HWS warrants that the findings contained herein have been collected with the level of care and skill exercised by experienced and knowledgeable environmental consultants who are licensed or otherwise trained to perform asbestos inspections pursuant to the scope of work required on this project. 1.07 SAMPLING RATIONALE/INSPECTION METHODOLOGY HWS performed an asbestos inspection in general accordance with the guidelines of the Environmental Protection Agency (EPA) National Emissions Standards for Hazardous Air Pollutants (NESHAPS), the Asbestos Hazard emergency Response Act (AHERA) and the Occupational Safety and Health Administration (OSHA) 1926.1101. The EPA recognizes material that contains greater than one-percent asbestos to be ACM. This was a non-destructive inspection, therefore the following materials were excluded from sampling: roofing materials, inaccessible materials, electrical components and fire doors. The CMU exterior walls were drilled into and no insulation (vermiculite) was discovered. One hundred and nine (109) samples of suspect ACM were obtained by HWS on December 19 and 26, 2007; and January 11, 2008. The types of materials sampled included laid-in ceiling tiles, acoustic ceiling texture, blown-in insulation, block filler, wallboard texture, wallboard and associated compound, base cove adhesive, floor tile and associated mastic, sheet flooring and associated mastic, and block texture. Additionally, fifty-seven (57) XRF shots were taken of painted surfaces on December 28 in order to identify LBP. The asbestos samples were submitted to Reservoirs Environmental, Inc. and DCM Science Laboratory for analysis by Polarized Light Microscopy (PLM). 1.08 FINDINGS/RECOMMENDATIONS ASBESTOS CONTAINING MATERIALS: + Acoustic ceiling texture and associated overspray. + Exterior block filler patch. + Wallboard j oint compound + Floor tile and associated mastic. + Sheet flooring mastic. + Lamp ballast wiring is assumed to be asbestos containing. + Fire doors are assumed to be asbestos containing. MATERIALS DETERMINED TO BE NEGATIVE FOR ASBESTOS: • Wallboard. • Exterior block filler. • Laid-in ceiling tiles. • Base cove adhesive. • Blown-in insulation. • Wallboard and block texture. MATERIALS DETERMINED TO BE POSITIVE FOR LEAD BASED PAINT: • No lead based paint was identified. ADDITIONAL FINDINGS: • All lamp ballasts will be treated as PCB containing. • All fluorescent tubes will be treated as mercury containing. • No mercury containing switched were identified. All fluorescent tubes are assumed to be mercury containing unless otherwise identified. No mercury containing switches were identified. HWS recommends that prior to demolition, the acoustic ceiling texture on the two interior soffits (310 sqft and 150 sqft) and associated overspray (2000 sqft and 500 sqft footprint, 20' to deck) be abated. The exterior block filler patch should also be removed (est. 72 sqft), as well as the lamp ballasts (est. 830) with their associated wiring and fluorescent tubes (est. 1026). Suspect fire doors can be evaluated one at a time during abatement and disposed of properly. HWS also recommends that the floor tile be taken up and disposed of as ACM waste (est. 31,000 sqft) in order to eliminate the liability associated with leaving ACM behind in the soil post demolition. If the floor tile mastic were also abated, the concrete pad for the building would be available for recycling. In either case, the wallboard joint compound can be demolished with the building if kept adequately wet when disturbed. Reference Attachment #2 for Asbestos Bulk Sampling Summary Table and Sampling Locations Drawing. Reference Attachment #3 for Asbestos Laboratory Analysis Report. Reference Attachment #4 for Asbestos Laboratory Accreditations. Reference Attachment #5 for Asbestos Location Drawing. STATE OF COLORADO A,SBEST'08· CERTIFICATION* <,\~' polqrado.Depattl1't·~~t9fPubllC:;H~:&1t11,; aridEnvir6nmerif· . .. f\irP>9!!~~;:~~i~~~~~t~\Y'~I?il . . ' •... ~ ',,,',,"" "J'; ".';.;,., .. ). ~,' :,,<;.;f~}/~ .. _\_ " ,',' '-', '/ "'~.':>';:{ ';; {~~,:.'. ;:~>;~;:i:~~:;:.~~··:\::·;· {,""".:' ',' "gas met th6Teq\lir,~111ent~i';2t25p~'~5q~" C~~s:~{ an,tAir:;611~lity 2~nt1,\bl Commission,Regi.l:l~tiqJ?-Nbi8;;~:'l:rt'iB;;:ahd i§~l1~re,:py q~rtified by the .'.' 'stat~ (),f:;Go19rftgQjIltg~ JQJ19W1gtdl§'cipline:'< ' .', /f:.'.~ \\" . ,.-. \~'~'-"i';" ~,,:;,:/.,~ :/ '-. ",'d: &+li .",,t,:;';;; ,.,.", . ..,';.,. .', j',::";" ' . . . B unaillgI,ns Pl~:~t~r:;~,~'(L' ',,;' ;: "'. " ;" .;: Issued: 2128/2007', \"",: Expires on: 2/28/2008 * This certificate is valid only with the possession of a currellt Division-approved training course certification in the discipline specified above. John Gaddis 7951 E. Maplewood Ave., #122, Greenwood Village, CO 80111 has successfully completed the EPA/ Colorado Approved AHERA ASBESTOS BUILDING INSPECTOR RE-CERTIFICATION COURSE For purposes of accreditation required under Section 206 of the Toxic Substances Control Act (TSCA) and the Colorado Department of Public Health and Environment Regulation #8. Conducted by MISERS INSPECTION & TRAINING, INC . . 1825 West Baker -Englewood, Colorado 80110 This course has been granted approval by: EPA Region: VIII The State of: Colorado (303) 922-8821 Office· (303) 922-0124 Fax Course Date: July 17, 2006 ABIR~40805-06 Certificate Number July 17, 2007 Expires on above Date STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public Health and Environment Air PollutioIlControl Division This certifies that .. Landon Moody Certification No: 10656 has met the requirements of25::-7-507, C.R's. and Air QuaJity Control Commission Regulation No. 8, Part B, and is hereby certified by the state of Colorado in the followil1gdiscipline: . Building Inspector* --3/4/2007 Expires on: 3/412008 * This certificate is valid ollly with the possessioll of a current Divisioll-approved trailling course certification ill the discipline specified above. 14367 Lakeview Lane, Broomfield, Colorado 80020 Tel: 303.424.4647 Fax: 303.432.8669 CERTIFIES THAT LANDON MOODY Has successfully completed The EPA-Approved AHERA Annual Refresher Course for INSPECTOR . This course is EPA-approved under Section 206 of the Toxic Substances Control Act (TSCA) and meets the requirements of Colorado Regulation NO.8. Course Date: Exam Date: Certificate No.: Expiration Date: 10/24/07 N/A AE07 -063-BI-R-05 10/24/08 /C~r<~ K. Jay ~:rridfmt STATE OF COLORADO LEAD-BASEDP AINT CERTIFICATION* Colorado Department of Public Health aIldEnvifbiline111 Air ponlltio~ Cpiitr()l Pivisi6h , '{\"c This certifies .that Certif'i~ati~~'~O:{~~71 Iia1ili~tthe'requirem~l1ts:Qt~5-7A1·()1,C:lt)~;.(a.w.~~.i\.ir ••. ~~~rrty"Cohtrpl COinm.ission Regulatio~~~.l~,,~qis~~r~pyee~ifiedbY~he. ~tate of . ColoraC1;oin~li.e follciwiIl~\iis~iplih~: .. . . , Issued: 12/3/2007 Expireson: 12/3/2010 * This certificate is valido~I~With fhe pos~ession of a validlead-based?oinftrainingcertificate in th~ disCipline specified above; issued bYf(ith~r a Colorado approved train~lIg provider, an EPA appr' d training prf/vider, or a training providerappn]vedbj} another EPA authorizedprogram. .' Benjamin Tuthill 7951 E. Maplewood Ave Siute 122 Greenwoodvillage, CO 80111 has successfully completed the required training hours required by Colorado Department of Public Health and Environment for; LEAD INSPECTOR REFRESHER COURSE F or purposes of accreditation under the Colorado Department of Public H~alth and Environment Regulation # 19 and other standards developed by EPA pursuant to Title IV of TSCA. Conducted by MISERS INSPECTION & TRAINING, INC. This course has been granted approval by: The State of: Colorado 1825 W. Baker Ave. -Englewood, Colorado 80110 (303) 922-8821 office (303) 922-0124 fax Course Date: November 6, 2007 Certificate Number k ~:2 --'-1~' 1M (iI~ -Instructor( s ) LIREF -84448-07 November 6, 2010 Expires on above Date This course has been granted approval by: The State of: Colorado Benjamin Tuthill 7951 E. Maplewood Ave Siute 122 Greenwoodvillage, CO 80111 has successfully completed the required 8hours required by Colorado Department of Public Health and Environmentfor; LEAD RISK ASSESSOR REFRESHER COURSE For purposes of accreditation under the Colorado Department of Public Health and Environment Regulation # 19 and other standards developed by EPA pursuant to Title IV of TSCA. Conducted by MISERS INSPECTION & TRAINING, INC. 1825 West Baker Ave. -Englewood, Colorado 80110 (303) 922-8821 office (303) 922-0124 fax Course Date: November 7, 2007 LRAREF -84448~07 CeJiificate Number h~ "'-7 ./ C;.. " .. .~: ... </t('%~ November 7, 2010 Expires on above Date SAMPLE DATE NUMBER 12119/07 ANT-CT1-01 12119/07 ANT-CT2-02 12119/07 ANT-CT3-03 12119/07 ANT-CT3-04 12119/07 ANT-CT1-0S 12119/07 ANT-CT4-06 12119/07 ANT-CT4-07 12/19/07 ANT-CT4-08 12/19/07 ANT-AT1-09 12/19/07 ANT-ATl-10 12/19/07 ANT-AT1-11 12119/07 ANT-CTl-12 12119/07 ANT-CTS-13 12119/07 ANT-CT6-14 12119/07 ANT-CT7-1S 12119/07 ANT-CT7-16 12119/07 ANT-CT7-17 12119/07 ANT-CT8-18 12119/07 ANT-CT8-19 12119/07 ANT-CT8-20 HWS Job # 73688401 ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue, Wheat Ridge, CO SAMPLE LOCATION MATERIAL DESCRIPTION Refer to drawing 2 'x4' white fisslperf laid-in ceiling tile (original pattern) Refer to drawing 2'x4' white fiss/perflaid-in ceiling tile (primary replacement) Refer to drawing 2 'x4' white small fisslperf laid-in ceiling tile (replacement) Refer to drawing 2'x4' white small fiss/perflaid-in ceiling tile (replacement) Refer to drawing 2 'x4' white fisslperf laid-in ceiling tile (original pattern) Refer to drawing 2'x4' white textured laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white textured laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white textured laid-in ceiling tile (yellow fiberglass) Refer to drawing Acoustic ceiling texture with sparkles -4% chrysotile -overspray present Refer to drawing Acoustic ceiling texture with sparkles -4% chrysotile -overspray present Refer to drawing Acoustic ceiling texture with sparkles -4% chrysotile -overspray present Refer to drawing 2'x4' white fiss/perflaid-in ceiling tile (original pattern) Refer to drawing 2'x4' white grid laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white multiple fiss/perflaid-in ceiling tile Refer to drawing 1 'xl' white fiss/perflaid-in ceiling tile Refer to drawing 1 'xl' white fiss/perflaid-in ceiling tile Refer to drawing 1 'xl' white fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white laid-in ceiling tile (yellow fiberglass) Refer to drawjng 2'x4' white laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white laid-in ceiling tile (yellow fiberglass) - ASBESTOS GREATER THAN 1% ND ND ND ND ND ND ND ND ! YES YES YES ND ND ND i ND ND ND ND ND ND ND -None Detected SAMPLE DATE NUMBER 12119/07 ANT-CT9-21 12119/07 ANT-CT9-22 12/19/07 ANT-CT9-23 12119/07 ANT-CT2-24 12119/07 ANT-CT6-25 12119/07 ANT-CT5-26 12119/07 ANT-CT5-27 12/19/07 ANT-AT2-28 12/19/07 ANT-AT2-29 12119/07 ANT-AT2-30 12119/07 ANT-CT10-31 12/19/07 ANT-CT10-32 12119/07 ANT-CTlO-33 12119/07 ANT-CT2-34 12119/07 ANT-CT3-35 12119/07 ANT-CTll-36 12119/07 ANT-CTll-37 12119/07 ANT-CTll-38 12119/07 ANT-CT12-39 12119/07 ANT -CTl2-40 HWS Job # 73688401 ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue~ Wheat Ridge~ CO SAMPLE MATERIAL DESCRIPTION LOCATION Refer to drawing 2 'x4' white fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white fiss/perflaid-in ceiling tile Refer to drawing 2 'x4' white fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white fiss/perflaid-in ceiling tile (primary replacement) Refer to drawing 2'x4' white textured laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white grid laid-in ceiling tile (yellow fiberglass) Refer to drawing 2'x4' white grid laid-in ceiling tile (yellow fiberglass) Refer to drawing Acoustic ceiling texture with sparkles -4% chrysotile -overspray present Refer to drawing Acoustic ceiling texture with sparkles -3% chrysotile -overspray present Refer to drawing Acoustic ceiling texture with sparkles -4% chrysotile -overspray present Refer to drawing 2'x4' white laid-in ceiling tile (wallboard) Refer to drawing 2 'x4' white laid-in ceiling tile (wallboard) Refer to drawing 2'x4' white laid-in ceiling tile (wallboard) Refer to drawing 2'x4' white fiss/perflaid-in ceiling tile (primary replacement) Refer to drawing 2'x4' white small fiss/perflaid-in ceiling tile (replacement) Refer to drawing 2'x4' white N/S fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white N/S fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white N/S fiss/perflaid-in ceiling tile Refer to drawing 2'x4' white chicken-foot laid-in ceiling tile Refer to drawing 2'x4' white chicken-foot laid-in ceiling tile ASBESTOS GREATER THAN 1% ND ND ND ND ND ND ND YES YES YES ND ND ND . ! ND ND ND ND . ND I ND I ND I ND -None Detected SAMPLE DATE NUMBER 12119/07 ANT-CTl2-41 12119/07 ANT-CTl3-42 12/19/07 ANT -CT13-43 12119/07 ANT -CT 13-44 12119/07 ANT-CTl4-4S 12/19/07 ANT -CTl4-46 12119/07 ANT-CT14-47 12119/07 ANT-INl-48 12119/07 ANT-INl-49 12119/07 ANT-IN1-S0 12119/07 ANT-CT1S-S1 12/19/07 ANT-CT1S-S2 12119/07 ANT-CTlS-S3 12/19/07 ANT-CT6-S4 12/26/07 AM-STl-55 12/26/07 AM-ST1-S6 12/26/07 AM-STl-S7 12/26/07 AM-STl-S8 12/26/07 AM-STl-S9 12/26/07 AM-STl-60 HWS Job # 73688401 SAMPLE LOCATION Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing Refer to drawing ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue, Wheat Ridge, CO MATERIAL DESCRIPTION 2'x4' white chicken-foot laid-in ceiling tile 2 'x4' white wide fissure laid-in ceiling tile 2'x4' white wide fissure laid-in ceiling tile 2'x4' white wide fissure laid-in ceiling tile 2 'x4' white solid fissure laid-in ceiling tile 2'x4' white solid fissure laid-in ceiling tile 2'x4' white solid fissure laid-in ceiling tile Blown-in insulation above ceiling tiles Blown-in insulation above ceiling tiles Blown-in insulation above ceiling tiles 2 'x4' plain white laid-in ceiling tile 2'x4' plain white laid-in ceiling tile 2 'x4' plain white laid-in ceiling tile 2'x4' white textured laid-in ceiling tile (yellow fiberglass) Refer to drawing Exterior white block filler -3% chrysotile -possible patch Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler ASBESTOS GREATER THAN 1% ND ND ND I ND . ND ND ND ND ND ND ND ND ND ND YES ND ND ND ND ND ND -None Detected SAMPLE DATE NUMBER 12/26107 AM-STl-61 12126/07 AM-TX2-62 12126/07 AM-TX2-63 12/26107 AM-TX2-64 12126/07 AM-TX1-65 12/26107 AM-TX1-66 12126/07 AM-BC1-67 12126/07 AM-TX1-68 12/26/07 AM-WBI-69 12/26107 AM-WB1-70 12/26/07 AM-WBI-71 12/26/07 AM-WBI-72 12/26/07 AM-WBI-73 12126107 AM-WB1-74 12126107 AM-WB1-75 12/26/07 AM-WBl-76 12/26107 AM-WB1-77 12126107 AM-WB1-78 12/26/07 AM-WBI-79 12/26/07 AM-WBI-80 HWS Job # 73688401 ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue, Wheat Ridge, CO SAMPLE LOCATION MATERIAL DESCRIPTION Refer to drawing Exterior white block filler Refer to drawing N wall white block texture Refer to drawing N wall white block texture Refer to drawing N wall white block texture Refer to drawing White wallboard texture Refer to drawing White wallboard texture Refer to drawing Base cove adhesive Refer to drawing White wallboard texture Refer to drawing Wallboard and associated compound -3% chrysotile in compound Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound -3% chrysotile in compound Refer to drawing Wallboard and associated compound -3% chrysotile in compound Refer to drawing Wallboard and associated compound -4% chrysotile in compound Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound -TR% chrysotile in compound Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound -4% chrysotile in compound Refer to drawing Wallboard and associated compound -4% chrysotile in compound ASBESTOS GREATER THAN 1% ND ND ND ND ND ND ND ND YES ND YES YES YES ND ND YES ND ND YES YES ND -None Detected SAMPLE DATE NUMBER 12/26/07 AM-WB1-81 12126/07 AM-WB1-82 12/26/07 AM-FT1-83 12/26/07 AM-FT2-84 12/26/07 AM-FT3-85 12/26/07 AM-FT4-86 12/26/07 AM-RM1-87 12/26/07 AM-FT5-88 12/26/07 AM-FT6-89 12/26/07 AM-FT7-90 12/26/07 AM-FT8-91 12126/07 AM-FT9-92 12/26/07 AM-FT10-93 12/26/07 AM-FTll-94 12/26/07 AM-FT12-95 12/26/07 AM-FT13-96 12/26/07 AM-FTI4-97 12/26/07 AM-FTI5-98 12/26/07 AM-FTI6-99 12/26/07 AM-SFI-I00 HWS Job # 73688401 ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue, Wheat Ridge, CO SAMPLE LOCATION MATERIAL DESCRIPTION Refer to drawing Wallboard and associated compound Refer to drawing Wallboard and associated compound Refer to drawing 12"x12" tan with purple streaks floor tile and black mastic -3% chry tile, 8% chry mastic Refer to drawing 12"x12" tan with brown streaks floor tile and black mastic-2% chry tile, TR% chry mastic Refer to drawing 12"x12" brown with white streaks floor tile and black mastic -3% chry tile, 7% chry mastic Refer to drawing 12"x12" white with black streaks floor tile and black mastic -3% chry tile, 10% chry mastic Refer to drawing Black remnant mastic -7% chrysotile Refer to drawing 12"x12" tan with heavy brown streaks floor tile and black mastic -2% chry tile Refer to drawing 12"x12" gray with brown and white streaks floor tile and black mastic -TR % chry mastic Refer to drawing 12"x12" tan mottled floor tile and black mastic -2% chry mastic Refer to drawing 9"x9" gray painted floor tile and black mastic -8% chry tile, 15% chry mastic Refer to drawing 12"x12" tan brick pattern floor tile and clear Refer to drawing 12"x12" cream with brown streaks floor tile and black mastic -2% chry tile, 7% chry mastic Refer to drawing 12"x12" gold floor tile and black mastic -2% chry tile Refer to drawing 12"x12" orange floor tile and black mastic Refer to drawing 12"x12" brown with white & black streaks floor tile and black mastic-2% chry tile, 2% chry mastic Refer to drawing 9"x9" tan with brown streaks floor tile and black mastic -5% chry tile, 3% chry mastic Refer to drawing 9"x9" gray with green streaks floor tile and black mastic -3% chry tile, 10% chry mastic Refer to drawing 9"x9" tan with large dark brown streaks floor tile and black mastic -2% chry tile, 3% chry mastic Refer to drawing Tan sheet flooring and black mastic -10% chry mastic ASBESTOS GREATER THAN 1% ND ND YES YES YES YES YES YES YES YES YES ND YES YES ND YES YES YES YES YES ND -None Detected SAMPLE DATE NUMBER 12/26/07 AM-FT17-101 12/26/07 AM-FT18-102 12/26/07 AM-FT19-103 12/26/07 AM-FT20-104 01/11108 AM-STl-10S 01/11108 AM-STl-106 01111108 AM-ST1-107 01111108 AM-STl-108 01111108 AM-STl-109 HWS Job # 73688401 - SAMPLE LOCATION ASBESTOS BULK SAMPLING SUMMARY 7340 West 44th Avenue, Wheat Ridge, CO MATERIAL DESCRIPTION Refer to drawing 9"x9 light pink floor tile and black mastic -2% chry tile, 15% chry mastic ----- Refer to drawing 12"x12" tan heavy mottled floor tile and black mastic -2% chry tile, 12% chry mastic Refer to drawing 12"x12" gray mottled floor tile and black mastic -5% chry mastic 12"x12" purple mottled floor tile and black mastic -2% chry tile Refer to drawing over 9"x9 green floor tile and black mastic -3% chry tile, 15% chry mastic Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler Refer to drawing Exterior white block filler ASBESTOS I GREATER THAN 1% YES YES YES YES ND ND ND ND • ND ND -None Detected .If::JI\Uf::JQ 8Lj8WQ U/oOU/7 L 0 /9 Z ;-2. I ( L. 0 I b ( I 1.1 :eleQ 8:Jf/U8S ljonOlljl suoUnJOS 7JI' + Wl CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W.49THAVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGEIOF8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -I ANT-CTl-OI -2 ANT-CT2-02 -3 ANT-CT3-03 -4 ANT-CT3-04 -5 ANT-CTl-05 -6 ANT -CT 4-06 -7 ANT-CT4-07 -8 ANT-C'T4-08 SAMPLE DATE DESCRIPTION A. WHITE PAINT B. TAN CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN CEILING TILE A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE RESINOUS COVERING B. YELLOW FIBROUS PERCENT OF SAMPLE 5.0% 95.0% 5.0% 95.0% 5.0% 95.0% 5.0% 95.0% 4.0% 96.0% 35.0% 65.0% 10.0% 90.0% 10.0% 90.0% TOTAL TOTAL PERCENTAGE ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS IDENTIFIED TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS MATERIALS ND 0.0 100.0 100.0 ND 90.0 10.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 90.0 10.0 100.0 ND ND 0.0 100.0 100.0 ND 97.0 3.0 100.0 ND ND 0.0 100.0 100.0 ND 97.0 3.0 100.0 ND ND 0.0 100.0 100.0 ND 97.0 3.0 100.0 ND CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE 2 OF 8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -9 ANT-ATI-09 -10 ANT-ATl-I0 -II ANT-ATl-ll -12 ANT-CTl-12 -13 ANT-CT5-13 -14 ANT-CT6-14 -IS ANT-CT7-15 -16 ANT-CT7-16 -17 ANT-CT7-17 SAMPLE DATE DESCRIPTION A. WHITE FOAMY TEXTURE A. WHITE FOAMY TEXTURE/ SILVER METAL (I) A. WHITE PAINT B. WHITE FOAMY TEXTURE C. WHITE DRYWALL MUD A. WHITE PAINT B. TAN CEILING TILE A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. YELLOW AND WHITE PAINT B. TAN CEILING TILE A. WHITE PAINT B. TAN CEILING TILE A. WHITE PAINT B. TAN CEILING TILE TOTAL PERCENT OF SAMPLE ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS 100.0% CHRYSOTILE [1-5] 4.0 0.0 96.0 4.0 100.0% CHRYSOTILE [1-5] 4.0 0.0 96.0 4.0 5.0% ND 0.0 100.0 25.0% CHRYSOTILE [1-5] 4.0 0.0 96.0 70.0% ND 0.0 100.0 1.0 6.0% ND 0.0 100.0 94.0% ND 90.0 10.0 ND 15.0% ND 0.0 100.0 85.0% ND 97.0 3.0 ND 4.0% ND 0.0 100.0 96.0% ND 72.0 28.0 ND 6.0% ND 0.0 100.0 94.0% ND 100.0 0.0 ND 4.0% ND 0.0 100.0 96.0% ND 100.0 0.0 ND 5.0% ND 0.0 100.0 95.0% ND 100.0 0.0 ND TOTAL PERCENTAGE IDENTIFIED MATERIALS 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE30F8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -18 ANT-CT8-18 -19 ANT-CT8-19 -20 ANT-CT8-20 -21 ANT-CT9-21 -22 ANT-CT9-22 -23 ANT-CT9-23 -24 ANT-CT2-24 -25 ANT-CT6-25 SAMPLE DATE DESCRIPTION A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE PERCENT OF SAMPLE 7.0% 93.0% 4.0% 96.0% 4.0% 96.0% 5.0% 95.0% 5.0% 95.0% 5.0% 95.0% 5.0% 95.0% 5.0% 95.0% ASBESTOS TYPE TOTAL ASBESTOS OTHER FIBROUS TOTAL PERCENTAGE NON-FIBROUS IDENTIFIED RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS MATERIALS ND 0.0 100.0 100.0 ND 96.0 4.0 100.0 ND ND 0.0 100.0 100.0 ND 96.0 4.0 100.0 ND ND 0.0 100.0 100.0 ND 96.0 4.0 100.0 ND ND 0.0 100.0 100.0 ND 73.0 27.0 100.0 ND ND 0.0 100.0 100.0 ND 73.0 27.0 100.0 ND ND 0.0 100.0 100.0 ND 73.0 27.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 72.0 28.0 100.0 ND CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE40F 8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -26 ANT-CT5-26 -27 ANT-CT5-27 -28 ANT-AT2-28 -29 ANT-AT2-29 -30 ANT-AT2-30 -31 ANT-CTlO-31 -32 ANT-CTIO-32 -33 ANT-CTlO-33 -34 ANT-CT2-34 SAMPLE DATE DESCRIPTION A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. WHITE RESINOUS COVERING B. YELLOW FIBROUS A. TAN FIBROUS B. WHITE FOAMY TEXTURE A. WHITE FOAMY TEXTURE A. WHITE FOAMY TEXTURE B. WHITEDRYWALLMUD A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE PERCENT OF SAMPLE 25.0% 75.0% 25.0% 75.0% 2.0% 98.0% TOTAL ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS ND 0.0 100.0 ND 97.0 3.0 ND ND 0.0 100.0 ND 97.0 3.0 ND ND 100.0 0.0 CHRYSOTILE [1-5] 4.0 0.0 96.0 3.9 100.0% CHRYSOTILE [1-5] 3.0 0.0 97.0 3.0 28.0% CHRYSOTILE [1-5] 4.0 0.0 96.0 72.0% ND 0.0 100.0 1.1 5.0% ND 0.0 100.0 95.0% ND 70.0 30.0 ND 5.0% ND 0.0 100.0 95.0% ND 70.0 30.0 ND 4.0% ND 0.0 100.0 96.0% ND 70.0 30.0 ND 5.0% ND 0.0 100.0 95.0% ND 70.0 30.0 ND TOTAL PERCENTAGE IDENTIFIED MATERIALS 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE 5 OF 8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -35 ANT-CT3-35 -36 ANT-CTlI-36 -37 ANT-CTII-37 -38 ANT-CTlI-38 -39 ANT-CTl2-39 -40 ANT-CTl2-40 -41 ANT-CTI2-41 -42 ANT-CT13-42 SAMPLE DATE DESCRIPTION A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. GREY FIBROUS C. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE TOTAL PERCENT ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS OF SAMPLE TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS 7.0% ND 0.0 100.0 93.0% ND 70.0 30.0 ND 4.0% ND 0.0 100.0 96.0% ND 76.0 24.0 ND 2.0% ND 0.0 100.0 98.0% ND 76.0 24.0 ND 2.0% ND 0.0 100.0 98.0% ND 76.0 24.0 ND 6.0% ND 0.0 100.0 94.0% ND 74.0 26.0 ND 5.0% ND 0.0 100.0 95.0% ND 70.0 30.0 ND 5.0% ND 0.0 100.0 15.0% ND 98.0 2.0 80.0% ND 72.0 28.0 NO 7.0% ND 0.0 100.0 93.0% ND 70.0 30.0 NO TOTAL PERCENTAGE IDENTIFIED MATERIALS 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 CLIENT: HWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE 6 OF 8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE NUMBER NUMBER -43 ANT-CTl3-43 -44 ANT-CT13-44 -45 ANT-CTI4-45 -46 ANT -CT 14-46 -47 ANT -CTl4-4 7 -48 ANT-INI-48 -49 ANT-INI-49 -50 ANT-INI-50 -51 ANT-CTI5-51 SAMPLE DATE DESCRIPTION A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN PERLITIC CEILING TILE A. WHITE PAINT B. TAN CEILING TILE A. WHITE PAINT B. TAN CEILING TILE A. WHITE PAINT B. TAN CEILING TILE A. TAN FIBROUS A. TAN FIBROUS A. TAN FIBROUS A. WHITE PAINT B. TAN CEILING TILE PERCENT OF SAMPLE 6.0% 94.0% 6.0% 94.0% 2.0% 98.0% 2.0% 98.0% 5.0% 95.0% 100.0% 100.0% 100.0% 5.0% 95.0% TOTAL TOTAL PERCENTAGE ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS IDENTIFIED TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS MATERIALS ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND ND 0.0 100.0 100.0 ND 90.0 10.0 100.0 ND ND 0.0 100.0 100.0 ND 90.0 10.0 100.0 ND ND 0.0 100.0 100.0 ND 90.0 10.0 100.0 ND ND 99.0 1.0 100.0 ND ND 99.0 1.0 100.0 ND ND 100.0 0.0 100.0 ND ND 0.0 100.0 100.0 ND 100.0 0.0 100.0 ND CLIENT: HWS CONSULTING GROUP, INC. 79S1 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCM SCIENCE LABORATORY, INC. 12421 W. 49TH AVENUE, UNIT #6 WHEAT RIDGE, CO 80033 (303) 463-8270 BULK ASBESTOS TEST REPORT PAGE 7 OF 8 ANALYSIS DATE: REPORTING DATE: RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: 12-21-07 12-26-07 12-20-07 73-68-8401 ANTIQUE MALL HWSC08839 PERCENTAGE COMPOSITION BY VISUAL ESTIMATE DCMSL CLIENT SAMPLE SAMPLE SAMPLE NUMBER NUMBER DATE DESCRIPTION -S2 ANT-CTlS-S2 A. WHITE PAINT B. TAN CEILING TILE -S3 ANT-CT1S-S3 A. WHITE PAINT B. TAN CEILING TILE -S4 ANT-CT6-S4 A. WHITE PAINT B. TAN PERLITIC CEILING TILE FOR CALCULATION PURPOSES, TRACE (TR) IS ASSUMED TO BE O.S%. (I) -INSEPARABLE LAYERS ND -NONE DETECTED PERCENT OF SAMPLE S.O% 9S.0% S.O% 9S.0% 4.0% 96.0% TOTAL TOTAL PERCENTAGE ASBESTOS ASBESTOS OTHER FIBROUS NON-FIBROUS IDENTIFIED TYPE RANGE % IN SAMPLE CONSTITUENTS CONSTITUENTS MATERIALS ND 0.0 100.0 100.0 ND 100.0 0.0 100.0 ND ND 0.0 100.0 100.0 ND 100.0 0.0 100.0 ND ND 0.0 100.0 100.0 ND 70.0 30.0 100.0 ND DeM Science Laboratory, Inc. 12421 W. 49th Avenue, Unit #6 Wheat Ridge, CO 80033 OCM Project No.: HWSCO 8839 Client Job No.: ANTIQUE MALL Bulk Sample Analysis BULK SAMPLE ANALYSIS PROCEDURES: Page '6 of 13 DCM Science Laboratory, Inc. analyzes bulk asbestos samples following procedures developed by the McCrone Research Institute and in compliance with guidelines established by the Environmental Protection Agency (EPA-600/R-93/116, July, 1993). Bulk samples are prepared for analysis using a 10X-80X stereo microscope in a hepa filter hood which provides a contamination-free environment. The sample is then analyzed by polarized light microscopy (PLM) at 100X. When the sample consists of more than one layer, each layer is prepared and analyzed separately. Fiber and matrix materials are identified by the characterization of optical properties including color and pleochroism, form, cleavage, relief, birefringence, extinction, orientation, twinning, interference figure and other distinguishing features. Dispersion staining is also used to further aid in mineral identification. All percentages of asbestos, other fibers and non-fibrous constituents are calculated from the values obtained from analyses using the stereo and PLM microscopes. In-house and NIST standards as well as a chart prepared by R.D. Terry and G.v. Chilinger for "The Journal of Sedimentary Petrology", (Volume 24, pp. 229-234, 1955) provide a guide for estimating percentages. All samples are archived for six months unless other arrangements are made by the client. ACCREDITATION: DCMSL is accredited by NVLAP (since April 1, 1989). Our NVLAP Lab Code is 101258-0. DCMSL complies with NVLAP requirements unless otherwise noted. ENDORSEMENT: The results of this analysis must not be used by the client to claim endorsement by NVLAP or any agency of the U.S. Government. This test report relates only to the items tested. This report may not be reproduced except in full, without the written approval of the laboratory. The analysis was performed by : Ron Schott Laboratory Director Date ~W~&$ NVLAP Lab Code 101258-0 I , HAZARDOUS MATERIAL DENVER OFFICE 7951 East Maplewood Ave., Suite 122 ANALYSIS REQUEST AND Greenwood Viliage, CO 80111-4724 303.771.6868 CHAIN OF CUSTODY SHEET Solutions Through Service \, To ~~UV\. Date I ;J'7 "," 7 di Project NoJ 7 '7:?-(,,71 55i+D I J)M Jnh P A N"'"rI, q I /.£2_ MA-d I J '2l2tJ/fr7 ( Attn. -HWS ~l'/\..lr-.lt:::' A-J)f.5 5c~~) ~ s~i We are sending you the following samples for analysis. No. of samples 5'-/ LAB SAtv iP_ETYPt: I.D. NO. FIELD l.D. NO. DATE TIME BULK AIR ANALYSIS WANTED VOLUME-cD A"'T C-T \0 I ~ C--i 2. -o-z.... PLM c..T <. "o~ T I CT-s.-''I ~',"S ~ Cj 1 -oC;-./ C, L/-ob 6/'-1-04- CI'-f -o.g A-T \ -0(1 1 0 \. \ GT\ \""2. r'T~'S ("XL", -\ l/ C T ::; I .::;- I~ <7 C-T'E1 \ <:,( 1:--' \ c1 " 20 Special instruction to Laboratory ~ '\.~ SAMPLE ~o~"d)CS \G/ " (~'"-~r COLLECTOR NAME (PRINT) 1\ SIG ~ATURE DATE I TIME \~HAIN OF CUSTODY \\ I ~ Relin ~uished By (SiQnature) DATE!TI~E '0 Recevied By (SiQnature) DATEITIME V-\1"\ " -_\~ \7/{ )4c4-Ii j () ri r:I It l-n=/"/l /u1 c? 7)1rrc~t 1,,!:/..o,v;ltj2 ()~ 1::/ f\ \ I \ ,,-J I I l \\1 Distri~on: Original: Accompanies Shipment. Please Sign and Return to HWS. Yellow: Retained by Laboratory Page_l_of -3 Pink: Project File 72-83 (1) DENVER OFFICE HAZARDOUS MATERIAL 7951 East Maplewood Ave., Suite 122 ANALYSIS REQUEST AND Greenwood Village, CO 80111·4724 303.771. 6868 CHAIN OF CUSTODY SHEET Solutions Through Service To ~CJv\ Date \?/!2cJjq r I Project No: Project ~Njl/v.e-M~l/ Attn. HWS contac~o \W r~)U We are sending you the following samples for analysis. No. of samples -5 Y I . -" SAMPLE -fYPE __ LAB I I.D. NO. FIELD 1.0. NO. DATE TIME BULK AIR ANALYSIS WANTED VOLUME (L) \~-.a C,q-Z! G.-"Z- 2-3 C.T2-2-l{ CTCo-~2:> C:-r-'5 -Z b L-f .A,~-c1$' Get ..30 CT\O-31 32.. . 3$' CT2--.3\.f CT s-3:;- L"-\\ -3.6 3f 3~ i -CI\~-3.g I l.-jO Special instruction to Laboratory \\ \\ 1\ SAMPLE -.J o 10 ~)cA LS. "\ \1\-( U Lclclff COLLECTOR NAME (PRINT) V 'SIGNATURE mATI! I TIME 1(HAIN OF CUSTODY J _\ ~ elinquished By (Signature) DATj::ITHyIE , Recevied By (Signature) DATEITIME " -~ 11-1 201 crt-Ii) 0 (I Olll /Y)CP)/ it d/ i)2t raJ f,1}{)f}(T 7 l,QIGC 'i 1\ ~ ~ l lJ . \ Distribution: Original: Accompanies Shipment. Please Sign and Return to HWS. Yellow: Retained by Laboratory Page -Z of 3 Pink: Project File 72-83 (1) DENVER OFFICE HAZARDOUS MATERIAL 7951 East Maplewood Ave., Suite 122 ANALYSIS REQUEST AND Greenwood Village, CO 80111-4724 303.771.6868 CHAIN OF CUSTODY SHEET Solutions Through Service To ~.~ Date \0 '2 c.:1 tJ7- Project No: [ I Project Ar0'/1~~ fI,~I±Jl . I Attn. HWS ContacL ~o~ c~ju We are sending you the following samples for analysis. No. of samples ---. - LAB SAMPLE TYPE 1.0. NO. FIELD LD. NO. DATE TIME BULK AIR ANALYSIS WANTED VOLUME (L) ~-G\I~-yl c, ''3 -'-\ 'L 43 1.../'-/ c-, I l\ -I.f c;,;;- 4Co LI1 TI0I,-~'< 41 s-o LI\~ -~, '5 L 53 C~~ S'-i '\. \ \ -i Special instruction to Laboratory \. \. SAMPLE _~.~ G--A-c}) f~ \f\ 1\ ' Ic:-/?JcJ7I COLLECTOR NAME (PRINT) \1 \ SIGNATURE DATE / TIME I~HAIN OF CUSTODY \ ~ "" Re.lin/i; uished By (Signature) DATE/TIME Recevied By (Siqnature) DATEITIME ~"\ ,\ ~ .,-\. ~ \ -v/2JlcA-l:l 0 ndl} (Y~ijl) .... d/J f')/))(;r.{j( ';}dD1Y] (fic r::; ~' \ '-."" I, I {J ~\ ~ Distributidn: Original: Accompanies Shipment. Please Sign and Return to HWS. Yellow: Retained by Laboratory Page Soil Pink: Project File 72-83 (1) January 2, 2008 Curtis Johnson HWS Consulting Gr. Inc. (CO) 7951 E. Maplewood Ave. Suite 122 Greenwood Village CO 80111 Dear Customer, Laboratory Code: Subcontract Number: Laboratory Report: Project Description: RES NA RES 148502-1 73688401.0100 Antique Mall Reservoirs Environmental, Inc. is an analytical laboratory accredited for the analysis of Industrial Hygiene and Environmental matrices by the National Voluntary Laboratory Accreditation Program (NVLAP), Lab Code # 101896 for Transmission Electron Microscopy (TEM) and Polarized Light Microscopy (PLM) analysis and the American Industrial Hygiene Association (AIHA), Lab ID 101533 -Accreditation Certificate #480 for Phase Contrast Microscopy (PCM) analysis. This laboratory is currently proficient in both Proficiency Testing and PAT programs respectively. Reservoirs Environmental, Inc. has analyzed the following samples for asbestos content as per your request. The analysis has been completed in general accordance with the appropriate methodology as stated in the attached analysis table. The results have been submitted to your office. RES 148502-1 is the job number assigned to this study. This report is considered highly confidential and the sole property of the customer. ReseNoirs Environmental, Inc. will not discuss any part of this study with personnel other than those of the client. The results described in this report only apply to the samples analyzed. This report must not be used to claim endorsement of products or analytical results by NVLAP or any agency of the U.S. Government. This report shall not be reproduced except in full, without written approval from Reservoirs Environmental, Inc. Samples will be disposed of after sixty days unless longer storage is requested. If you have any questions about this report, please feel free to call 303-964-1986. Sincerely, Jeanne Spencer Orr President Analyst(s): _________ _ Paul D. LoScalzo Paul F. Knappe Michael Scales P: 303-964-1986 F: 303-477-4275 Wenlong Liu Rich Wegrzyn 5801 Logan Street, Suite 100 Denver, CO 80216 Page 1 of 7 1-866-RESI-ENV www.reilab.com RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number / P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: IClient Sample Number AM-SI1-55 AM-SI1-56 AM-SI1-57 AM-SI1-58 AM-SI1-59 AM-SI1-60 AM-SI1-61 ND=None Detected TR=Trace, <1 % Visual Estimate TremHAct=Tremolite-Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27,2007 PLM, Short Report 3-5 Day December 31, 2008 Lab L ID Number A Y Physical E Description R EM 217246 A White plaster B Gray granular plaster C Green/multi-colored paint EM 217247 A White granular plaster B Green/multi-colored paint EM 217248 A Green/multi-colored paint B White plaster C Gray/white granular plaster EM 217249 A White plaster B Green/multi-colored paint C White granular plaster D Gray granular plaster EM 217250 A Green/pink paint B Gray granular plaster EM 217251 A Green/multi-colored paint B White granular plaster EM 217252 A Green/multi-colored paint B White granular plaster Note: Further analysis by TEI'v! is recommended for organically bound mate,;al (i.e, floor tile) ifPLM results are::; I 'Yo, Sub Part (%) 5 10 85 20 80 20 20 60 10 20 35 35 20 80 30 70 30 70 Asbestos Content Mineral Visual Estimate (% Chrysotile 3 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND Page 2 of 7 Analyst: LW -~ Non Non- Asbestos Fibrous Fibrous Components !components (%) 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~'~ Data QA (%) 96 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 DigItally Sl9f\OO by Gina Date 200601 02 14·53:3 1-07'00' RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number / P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: -_ .. IGlient Sample Number AM-TX2-62 AM-TX2-63 AM-TX2-64 AM-TX1-65 AM-TX1-66 AM-BC1-67 AM-TX1-68 AM-WB1-69 AM-WB1-70 AM-WB1-71 AM-WB1-72 ND=None Detected TR=Trace, <1 % Visual Estimate Trem~Act=Tremolite~Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27,2007 PLM, Short Report 3-5 Day December 31, 2008 -----_._---------Lab L ID Number A Y Physical E Description R EM 217253 A White granular plaster w/ white/gray paint EM 217254 A White granular plaster w/ white/gray paint EM 217255 A White granular plaster w/ white/gray paint EM 217256 A White plaster w/ gray/multi-colored paint EM 217257 A White plaster w/ gray/multi-colored paint EM 217258 A Brown mastic EM 217259 A White plaster w/ yellow/gray paint EM 217260 A Tan plaster w/ white/multi-colored paint B Tan/white drywall EM 217261 A White plaster w/ white paint B Tan/white drywall EM 217262 A Tan plaster w/ white/multi-colored paint B Tan/white drywall EM 217263 A White tape B Tan/white drywall C Tan plaster w/ tan paint Note: Further analysis by TEM is recommended for organically bound material (i.e. floor tile) ifPLM results are:ol %. Sub Part (%) 100 100 100 100 100 100 100 20 80 20 80 15 85 5 10 85 Page 3 of 7 Analyst: LW Asbestos Content Non Non- Asbestos Fibrous Fibrous Components Mineral Visual Components (%) Estimate (% (%) ND 0 100 ND 0 100 ND 0 100 ND 0 100 ND 0 100 ND 2 98 ND 0 100i Chrysotile 3 0 97 ND 10 90 ND 0 100 ND 10 90 Chrysotile 3 0 97 ND 5 95 ND 95 5 ND 3 97 Chrysotile 3 0 97 'I'l' Data QA RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number / P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: vlient Sample Number AM-WB1-73 AM-WB1-74 AM-WB1-75 AM-WB1-76 AM-WB1-77 AM-WB1-78 AM-WB1-79 AM-WB1-80 AM-WB1-81 AM-WB1-82 ND=None Detected TR=Trace, <1% Visual Estimate Trem~Act=Tremolite-Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27,2007 PLM, Short Report 3-5 Day December 31, 2008 Lab L ID Number A Y Physical E Description R EM 217264 A White plaster w/ white paint EM 217265 A White drywall EM 217266 A White drywall B White plaster w/ yellow paint EM 217267 A White/multi-colored paint w/ tan plaster B Tan/pink drywall C White plaster w/ gray paint EM 217268 A Tan/white drywall B White plaster w/ pink paint EM 217269 A White plaster w/ white/multi-colored paint B Tan/white drywall EM 217270 A White plaster w/ yellow paint EM 217271 A White plaster w/ yellow paint EM 217272 A White drywall B White plaster w/ pink paint EM 217273 A White plaster w/ pink paint B Tan/white drywall Note: Further analysis by TEM is recommended for organically bound material (i.e. floor tile) ifPLM results areSI 'Yo. Sub Part (%) 100 100 10 90 10 40 50 40 60 30 70 100 100 20 80 30 70 Page 4 of 7 Analyst: LW Asbestos Content Non Non- Asbestos Fibrous Fibrous Components Mineral Visual ~omponents (%) Estimate (% (%) Chrysotile 4 0 96 ND 2 98 ND 2 98 ND 0 100 Chrysotile TR 0 100 ND 10 90 ND 0 100 ND 10 90 ND 0 100 ND 0 100 ND 10 90 Chrysotile 4 0 96 Chrysotile 4 0 96 ND 3 97 ND 0 100 ND 0 100 ND 5 95 r: l' C;: ~!, Data QA RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number / P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: vlient Sample Number AM-FT1-83 AM-FT2-84 AM-FT3-85 AM-FT4-86 AM-RM1-87 AM-FT5-88 AM-FT6-89 AM-FT7-90 AM-FT8-91 ND=None Detected TR=Trace. <1 % Visual Estimate Trem-Act=Tremolite-Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27,2007 PLM, Short Report 3-5 Day December 31, 2008 Lab L ID Number A Y Physical E Description R EM 217274 A Black mastic B White tile EM 217275 A Black mastic B White tile EM 217276 A Black mastic B Brown tile EM 217277 A Black mastic B White/gray tile EM 217278 A Black mastic EM 217279 A Black mastic B White/brown tile EM 217280 A Black/brown mastic B White tile EM 217281 A Black/brown mastic B White tile EM 217282 A Black mastic B White leveler C Tan tile w/ gray paint Note: FUl1her analysis by TEM is recommended for organically bound material (i.e. floor tile) if PLM results are:::;1 %. Sub Part (%) 3 97 5 95 3 97 2 98 100 2 98 3 97 5 95 2 13 85 Asbestos Content Mineral Visual Estimate (% Chrysotile 8 Chrysotile 3 Chrysotile TR Chrysotile 2 Chrysotile 7 Chrysotile 3 Chrysotile 10 Chrysotile 3 Chrysotile 7 ND Chrysotile 2 Chrysotile TR ND Chrysotile 2 ND Chrysotile 15 ND Chrysotile 8 Page 5 of 7 Analyst: LW - Non Non- Asbestos Fibrous Fibrous Components K;omponents (%) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ~~- ~ / (%)! 92 97 100 98 93 97 90 97 93 100 98 100 100 98 100 85 100 92 ~~n:r ¥~~:~ "' 14 ~J.O~ ..(17'01)' Data QA RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number I P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: IClient Sample Number AM-FT9-92 AM-FT10-93 AM-FT11-94 AM-FT12-95 AM-FT13-96 AM-FT14-97 AM-FT15-98 AM-FT16-99 ND=None Detected TR=Trace, <1 % Visual Estimate Trem-Act=Tremolite-Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27,2007 PLM, Short Report 3-5 Day December 31, 2008 -------- Lab L ID Number A Y Physical E Description R EM 217283 A Brown/yellow mastic B Yellow/white tile EM 217284 A Black mastic B White/brown tile EM 217285 A Black mastic B Brown tile EM 217286 A Black mastic B Orange tile EM 217287 A Black/brown mastic B Gray tile EM 217288 A Black felt wi black mastic B White tile EM 217289 A Black mastic B Green tile EM 217290 A Black mastic B White tile Note: FUl1her analysis by TEM is recommended for organically bound material (i.e. floor tile) ifPLM results aresl %. Sub Part (%) 5 95 2 98 3 97 4 96 TR 100 10 90 2 98 2 98 Asbestos Content Mineral Visual Estimate (% ND ND Chrysotile 7 Chrysotile 2 ND Chrysotile 2 ND ND Chrysotile 2 Chrysotile 2 Chrysotile 3 Chrysotile 5 Chrysotile 10 Chrysotile 3 Chrysotile 3 Chrysotile 2 Page 6 of 7 Analyst: LW Non Asbestos Fibrous Components (%) 0 0 0 0 3 0 0 0 0 0 17 0 0 0 0 0 'i'l Non- Fibrous Components O;;/''''~y .13"~~ ft~~ (%) 100 100 93 98 97 98 100 100 98 98 80 95 90 97 97 98 Data QA RESERVOIRS ENVIRONMENTAL, INC. NVLAP Accredited Laboratory # 101896 TDH Licensed Laboratory # 30-0136 TABLE PLM BULK ANALYSIS, PERCENTAGE COMPOSITION BY VOLUME RES Job Number: Client: Client Project Number / P.O.: Client Project Description: Date Samples Received: Analysis Type: Turnaround: Date Analyzed: IClient Sample Number AM-SF1-100 AM-FT17-101 AM-FT18-102 AM-FT19-103 AM-FT20-104 ND=None Detected TR=Trace, <1 % Visual Estimate Trem-Act=Tremolite-Actinolite RES 148502-1 HWS Consulting Gr. Inc. (CO) 73688401.0100 Antique Mall December 27, 2007 PLM, Short Report 3-5 Day December 31, 2008 Lab L ID Number A Y Physical E Description R EM 217291 A Black mastic B Brown sheet flooring EM 217292 A Black mastic B White tile w/ gray paint EM 217293 A Black/yellow mastic B White tile EM 217294 A Black/yellow mastic B White/gray tile EM 217295 A Yellow mastic B Black mastic C Green tile D White/brown tile Note: Fut1her analysis by TEM is recommended for organically bound matenal (i.e. floor tile) ifPLM resuits areS I %. Sub Part (%) 2 98 2 98 2 98 5 95 1 4 45 50 Asbestos Content Mineral Visual Estimate (% Chrysotile 10 ND Chrysotile 15 Chrysotile 2 Chrysotile 12 Chrysotile 2 Chrysotile 5 ND ND Chrysotile 15 Chrysotile 3 Chrysotile 2 Page 7 of 7 Analyst: LW Non Asbestos Fibrous Components (%) 0 15 0 0 0 0 0 0 0 0 0 0 .. ~ Non- Fibrous Components o.GM~y "''1''<:<1 byG .. " r~:'o 14.525 .tlroO' (%) 90 85 85 98 88 98 95 100 100 85 97 98 Data QA Due Datfl:/~_'J-/ / ~.'i 48502 Due Tlm.~: S '. c:-Page _ of SU13MfTTED BY: fNVOICE TO: tv0 ANALYSIS VALID CODES LAB NOTES: -,' _ Air" II Bolk ~ B ~ 0 ________ ._~~----.~~--~------~---------.--~--.------~.--------.-------------___ ~ § 6 ~ _________ . _____________________________ "'--_______ ---'--__ . _______ . __________ ----1 ~ 'j' g ~~i(:Jil::; vV [ll.9t<1l(s) rOllS! 24 he .15 Day ~ c;·~.:;: Drmki!l9 WaV'!f = DW Cl. , .. ' I,} '!,. ~.. ~' UPriOl' notific~)1hm i:-> t: ~ b ~'. ~B V·)tft~):H~ VI/ater :::: F:U~,6,,, I M·)tals & VI(ddlng ;~USH S day '10 day reqldred lor RUSH ~:~ E:'5 ~ '" Other" 0 FUrno Scan I TCLP til '"Ja"Qund~ _,;I 2 ~ ~ ':i (f:!l .~:; ui !l~,~. ti; .. :::2 0:, .-ru h.}\STi\.tE1r9~~,_;pprov.eti "'led!Oor.l't'''~ ________________ --:;,-._., __ ,-__ . ____________ . ___ ._. ________ . _______________ , i i : ~ L;J P ------:14 hI. OJ E :;} C :> f) 7' 81 9 '>~ YX2 G. '2; \..;:x;, t...:> I (p ') .-:: l~r Date Time Collected COHf:CtBd rnm'..Jzh:Y hh-'mm/?r{) EM Numhor (LtJiJ0rt"ltory U,,>; ():)ly) ::;7 REQUESTED ANALYSIS VALID MATRIX CODES LAB NOTES: "0"(5~;f14!; c ! ro !@ I Air=A l Bulk" B FII;;;;! l.AS i7ilI:::::::::!JU::::w ~ .r: 3 « .... ".~v a x Dust = 0 Paint = P ~r~f!ll)" .. , ::> 0 a (3 ..::8. cr 0 .. C t ~ n:: Soil = S Wipe = W 0 C· o. 0 .!J.!~~~ingWater " OW Q eD O c' . I .. -e t<;,l;O RES Job # j V r(~ 2- "-f (.)'t> Waste Water" WW .~ ",-g (j) N ....... Page_2_ of.,.,...2... « '" tiC.> e ~-; I ~ If:I Other" 0 f,? :g i3 %i .......... I· ... :;;0 i-"ASTM E11"92 approved '';lpe media only" 0; ii> g-o:; e . :::: 1,-""", ....... -...... ..J i; , t ! ' ~ '5.. (h" ~ . t fu :r U'1 ~ ...... ' I············· .. ········ Submitted by: \~-{_0_\ ..J e & !~ . ::> x 8. '" U,..~ ~ ) . ., <' -.! ~ I·· .. "' &:£ <:J>; CfJ t .. ~ !< <;:; .2 (J) ~ B ~ c~ ~i~:~ f2:.iJ o 1;> <lJ .-.. if) ;!( CJ ~; ~ . ~ ~ <3 ~ Date Time ;;;I , '1..J .::i ffi ~ I ~ I :E t; i~ ~ ~ ~ ~:::: .~ 0 Collected Collected EM Number (LaboratoPli Client sample 10 number (Sample ID's must be unique) o ::I' ~ 0 0 m:J' ~ (): mmiddtyy l'1.hJ01-'!! alp Use Only) , C. 0 t c/)~. :;;, 14 Q.V\ -r~~ .9Y~ , ... + "'1 ) ·+ .... +·1 .... 1_,;1.1 :7 2,,'(~j 15 ,---,v .. (,;, (( ...... ..... , ............. ; ; ,{( .... 16 71:...' : i ... L .. t . (,J / 17 .;:z ! • ..l, J ; ..... I .. ' !. :.2- "" 18 72-i i ; 19 7-3 •... ~ : ..... -.... /;: (/ ; 20 ~7l-~1 ; , I i tel l/ 21 ;"''> .: c-l-l-I ;51 [ 22 ./: \...0 -'" ...... -.,,- i l.~ ) 23 1-:; '{~l' 24 IV ..... I~ 25 r"1 --.. _ ... _-, .... , I '}T' ; 26 ___ .... _ ........ _ ....... _._ ....... ___ . .s::::::.. _ .... ! i j "27 ------~--~-------.-"-.--.. --------.---.------.~-- c;I,! i I i .~;ZL... 28 <:(. 2-l' i -:71' 29 .. F'.I Y~S __ .... i---I , ,:1,/ i 30 r:r2 -S-~ i 1 -Z( 31 C,--;Z··· ~ i ->(: 32 t:. ,'1....( -'Y--Co ~ __ L i -:77 33 /2...;-./\, i" <~-7 i ') t 34 --,.-= .. ~1[ ... _ i j i I ;JG7" 35 '("" .. :~-;1 : I I Su 36 F.,-7-'i G-' ! I : .~. L .... 37 ~ •• ~~~~.:: . ;;?~: ;··t·········-!·· ··I···-·······~· Y2._ 38 ......•... ....... i·'-·-· .. ·· ; .... . ....•... . _ ... . ...... -;-, ... ·f·tr -i -"~--,, .•. --~ 39 ..,.. Ie; 1,'3 40 r--,--'[ \ -'I ~I ,', . ........ ! ",,\ 41 F T ( L.., "1":; i ~;' L., 42 F -, ,~ ':rl, ; ; ~},-43 C-. ,c"--'1+ _ ....•... -.+~ ...... i-' ........ ...... "rl . ...... , ..... -...• -.. -..... ~, 44 C, l c.:::: .. 'i<'( ; : J":7 f~ES Job Submitted SO 51 52 53 54 66 56 57 58 59 60 61 62 63 64 65 66 67 68 G9 70 71 72 73 74 76 ~ ~~~~/S r.: Z~ C -:;. Page of g e t~ C') :1 ...J "- RE(WESTED ANALYSIS VALID MATRIX CODES __ ._ __ _ ~ 6 ". ;':" ;' e; "'" ;:: .. ~ g ~f ~ ;::'0 ,!) i5 c": > OJ 01 > .j c lli~ '~f :E W I- C() ~1. 0' () ~ <: I if} 0'13 oi " 0 5. 0 ·,0 ~ " r~ c: ," 0 [fj 1/, "§ OJ ~ Bulk" 8 Air~A Dust'" 0 80il= 8 Pilm!" P W;P0" '-IV Water" DW Waste \!Vater" WW Olher" 0 O:J)I:·r0ved _q:::(" tne(i1a DRAFT CLIENT I-lWS CONSULTING GROUP, INC. 7951 E. MAPLEWOOD AVENUE, SUITE 122 GREENWOOD VILLAGE, CO 80011 DCMSL CLIENT SAMPLE SAMPLE SAMPLE NUMBER NUMBER DATE DESCRIPTION -IRR AM-STI-I05 A WHITE CONCRETE B. MULTICOLORED PAINT -2RR AM-STl-I06 A WHITE CONCRETE B. MULTICOLORED PAINT -3RR AM-STI-I07 A WHITE CONCRETE B. MULTICOLORED PAINT ARR AM-STl-I08 A WHITE CONCRETE B. MULTICOLORED PAINT -5RR AM-STI-I09 A WHITE CONCRETE B. MULTICOLORED PAINT FOR CALCULATION PURPOSES, TRACE (TR) IS ASSUMED TO BE 0.5%. (I) -INSEPARABLE LA YER~ NO -NONE DETECTED DCM SCIENCE LABORATORY. INC. 12421 W.49THAVENUE,UNIT#6 WHEAT RIDGE, CO S0033 (303) 463-S270 BULK ASBESTOS TEST REPORT PAGE I OF2 ANAL YSIS DATE: REPORTING DATE RECEIPT DATE: CLIENT JOB NO.: PROJECT TITLE: DCMSL PROJECT: PERCENTAGE COMPOSITION BY VISUAL ESTIMATE PERCENT ASBESTOS OF SAMPLE TYPE RANGE 25.0% 75.0% 5.0% 95.0% 7.0% 93.0% 3.0% 97.0% 3.0% 97.0% I-II-OS 1-11-08 1-11-08 73-68-8401.0 I 00 ANTIQUE MALL HWSC08840 TOTAL ASBESTOS % IN SAMPLE NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO OTHER FIBROUS CONSTITUENTS 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 TOTAL PERCENTAGE NON-FIBROUS IDENTIFIED CONSTITUENTS MATERIALS 100.0 100.0 1000 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 The American Industrial Hygiene Association m:kl1(Jwledges that c.EI.teR. 30 T:7: ofAIHA l.lls DCMScience Laboratory 12421 West 49th AveDlle, Unit 6, Wheat Ridge, CO 80033 LaboJ'atory ID: 101526 has M(jJled ihe requirements of the.AlHA Laboratory.Qun lity Assurance Programs (LQAP), thereby, conform ing to the lSO/LEe 17025: 1999Jntematfonal standard,; General Re([uireilUintsJdr the COlllpelellce a/Testing and Calibra{ion.Laboralol'ies. The above named laboratory> along Wit11 aU premIses [i·om wh lcll key activIties are perfornled, as listed above,}lave been accredited . by AlBA in the folLowing: ACCREDITATION PROGRAMS ./. o o o INDUSTRIAL HYGIENE ENVIRONMENTAL LEAD ENVIRONMENTAL MICROBIOLOGY FOOD Accreditation Expires: 05/01/2008 Accreditatiol1 Expires: Accredita60n ·Expires: Accreditation Expires: Speci.flc Field(s) ofTestilig (FoT)!Method(s) withineacb Accreditation ProgramJof whIch tbe above named laboratory maintaius accreditation is outlined au. the attached Scope of Accreditation, Gontitlue.daccreditation is contingent upon successful all-going compliance with LQAP requirernelits. This certificate is not valid without the attached Scope "fAccreditation. ~~~~~ David Kahane,. CJH ChaIrperson, AnalpffcalAccrc:ditatlon Board .~~ 7J1 ,'1?~'-' Frank Me Renshaw, PhD, CIH, CSP PrEsldellt, AIHA Date Issued: 0512412006 United States Department of Commerce National Institute of Standards and Technology Certificate of Accreditation to ISO/IEG 17025: 1999 NVLAP LAB CODE: 101258-0 DCM Science Laboratory, Inc. Wheat Ridge, CO is recognized by the National Voluntary Laboratory Accreditation Program for conformance with criteria set forth in NIST Handbook 150:2001 and all requirements of ISOIIEG 17025:1999. Accreditation is granted for specific services, Nsted on the Scope of Accreditation, for: BULK ASBESTOS FIBER ANALYSIS ",,,,liT OF Co ¢-~'Ir.", f;"" ~C> C) .~. ~ * * __ ~J.~ 2007-04-01 through 2008-03-31 ~ ~-. (J ~ <t: "'c ~v; 6'7"~-rES 0'" 1>' For the NalionailnsMute of Standards and Technology Effective dates NVLAP-01C (REV. 2005-05-19) National Voluntary Laboratory Accreditation Program SCOPE OF ACCREDITATION TO ISOIIEC 17025:1999 DCM Science Laboratory, Inc. 12421 W. 49th Ave., Unit 6 Wheat Ridge, CO 80033 Ms. Cindy Mefford Phone: 303-463-8270 Fax: 303-463-8267 E-Mail: dcmscilab@aol.com URL: www.dcmsciencelab.com BULK ASBESTOS FIBER ANALYSIS (PLM) NVLAP LAB CODE 101258-0 NVLAP Code Designation / Description 18/AO I EPA-600/M4-82-020: Interim Method for the Determination of Asbestos in Bulk Insulation Samples 2007-04-01 through 2008-03-31 Effective dates Page I of 1 NVLAP-01 S (REV. 2005-05-19) United States Depa,rtment of Commerce National Enstitute 'o,f Standards and TechnoWogy rt· ·f~; ........... ·t·· ...... . ... f···. A'· •.•...... '.' ....... ' .. ··d····. 'tot·· . t··· .. ", · " t:,·, 'I' S' ' ..•. ·0'·', /., 'I'E""C" '·1. ·7···· 0'·' ·2····· 5·· .• 2···· 0,.'· 0" 5 el Ica,.e' o > cere :1 a Jo,n0 ; ..'.'i .... ' ".:' .•.... N,tLAJJ; LAB CODE: 101896",0: R · E'" tI'1 :.esel'VOII'S' nVlronmena., JIlC .. , Denver; CO is accredited by the Mettonal VO/Lmtt:uy LaborctfOty AcctecmaNoll Program for specific sfNvices, fisted on the Scope' ofAccreditatitJn, for: B,····U·:I' ,KA·S·'B'··E· S··T"··OSI:{"'\·IBE'R·····.··A·N···'A····I· y. ·S···'IS ' "!"". .....' ..... :, ' , .... : ..... _ ..... :.,.~..... . ',.l' '.. '. This laboratory is accredited in 1;flcooroance Wftfi the recognIzed international Stam:tard fSOllEC1 7Q25:>2005,. Thisaccreciftation demonstrates technical competence for ,8 defined scope and the ,operation of 8 laboratory quality management system (refer to joint fSO-lLAC4AF Communique dated 18 June 2005). 2007-07-01 through 2008~06-30 'Ii' ,~~==~~~----------------------~~~-~-~---..... --------------------------------------N';ltAfoJ·'tl'l C ,;RE::V, 2DOG,{)9,13) ,. . ... ·1 : ..., ; National, Voluntary ~• ® .····.-;· .. ·.i·· ~w· _Z@~atol'}' AC(~re~it~til)n ProgralTl SCOPE OF ACCREDITATMONTO ISO/lEe )7025:2005 Reserv{Jirs Envir(lmnental~ Int. Logan Street, toO CO 80216 Ms. Jeamle SpenceI' Orr Phone: 303-964m 1986 Fax: 303~471~4215 IE.~Mail: jcmmeorr@reilab.cOl1l \V,\'\\?~reHab,cnm BULK ASBESTOS FfBER. AN.4.L YSIS (Pllvl) NJ/LAP Coile l'esigrl'tltkm l Descripti(Nl 18lAOl EPA~600lM4~82~O:tO: InteriniMetlilod the Smtiples: NVLAP l.AB e01lE Hl1896-0 -! -@ i :elil:!d L 0 /9 Z / 7..1 ( L 0 / 6 ( (2 ( :eJI:!O 8:J!A18S ljf5nOJljl SUO!Jn/os Appendix H Higgins and Associates Asbestos Report 7300 W. 44th Ave April 14, 2010 Mr. Patrick Goff Deputy City lvlanager City of Wheat Ridge 7500 W. 291h Avenue Wheat Ridge, Colorado 80033 Re: Limited Asbestos Survey 7300 W. 44tll Avenue Wheat Ridge, Colorado 80033 lIiggills {lmilissoeiatf!S, IlC Per your request, Higgins and Associates performed a limited asbestos identification survey on Aplil 12, 20] 0, at the above reference location. The following report contains the findings from that survey. Higgins and Associates appreciates the opportunity to perform quality EH&S services for the City of \"'heat Ridge. Please call me at 303-708-9846 if you have any questions or ~com111ents regarding the survey. Sincerely, Higgins and Associates, LLC Mike Semonisck, MS, BS, ABI, AMP, APD, AMS, CM] Manager of Asbestos/Mold Assessments B~OO South Akron Sl/eet. Suite 117 Centennlol. Colorado 80112 Phone 303·708-9846 • Fax 303~708·9840 ( LIMITED ASBESTOS SUHVEY INYENTORY OF 7300 W. 44'" A VENUE WHEAT lUDGE, COLORADO PREJ'ARED FOR: CITY OF WHEAT Rll)GE 7500 W. 29'" A VENUE WHEAT RIDGE, COLORADO APRIL 14, 20 HI PREPARED BY: HIGGINS AND ASSOCIATES 820() SOUTH AKRON STREET, SUITE 117 CENTENNIAL, COLORADO 80112 (303) 708-9846 1.1 INTlWDUCTION SECTION 1.0 GENERAL PRO.JECT INFORMATJON This limited rlsbeslos inspection report presents data which describe the condition and location of a~bcstos-e{)ntaining material (ACM) idcntificd at the facility located at 7300 W. 44'" Avcnue in Wheat Ridge, Colorado. This report is to be used as H program planning tool for <111 constructioll, maintenance, and demolition activities scheduled at this tilCility. All AeM identificd in this report should be handled in accordance with all applicable federal, statc, and local regulatory requirements. To facilitate compliance with City of Wheat Ridge management polie)', and as ,m aid 10 minimize employee exposure, this inspection report should illso he used in conjunction with an Onerations and Maintennllcc Policy Manual for Ashestos-Containing ivfnlcrials. Appropriate pcrsonnel should be trained to usc this inspection report in conjullction with planned Operations & MaintclUmce (0&1"0 activities or renovations so these activities arc conducted properly. This will assist in preventing potential exposure to airbomc asbestos fibers, or the creation of an emergency abatement or clean-up operation. The combined goals of the sampling and visual (U;scssmcnts are as (ollows: I) identify ACM at the facility ancl document the condition, friability, location. and quantity of each identified material; and 2) consolidate sample data and obserl'ations obtained during thc site visit into repoli form, applicable parts of which will be incorporated into a facilit), O&M Manual (where relevant). 1.2 INSPECTION AND SAMPLING PROCEDURE Higgins and Associates inspection and sample collection procedures are based Oil the Asbestos Huzard Emergency Response Act (Al-IERA) ami Environmental Protection Agency (EPA) protocols. An initial facility walk-through is conductcd to familiarize the inspector(.) with the facility layout. The facililY drawings (if available) arc reviewed for accuracy and suspect materials arc idcntified. The facility is thcn divided into functional spaccs and suspcct homogeneous materials arc sclected for bulk sampling. Samples arc collected and placed into separate, sealed plastic bags. Each sample is individually numbered, and sample information is entered onto a Ficld Datu Sheet. Sample tools are decontmninnlcd after each sample collection" The samples nrc delivered to em accredited laboratory for anulysis, each accompanied by n completed Chain of Custody Form. lIiggins lIlUl As.wu:iute,\", III' ( Limited Asbestos Survc\, 730(1 W. 44tl. Ave. . Wheil! Ridg.c, Colomdo Suspect materials arc divided into three categories: surfacing materials (such as plaster ami surface coatings), thcnnal system insulation (TSI) (such as mudded TSI fittings, duct insulation, and pipe insulation), and miscellaneolls material (snch as floor tile, drywall. and mastic). Asbestos-containing materials are classified according 10: Condition • Good " Damaged o Significantly Damaged Fl'iability • Friable • Non-friable Potential for Disturhance • Low Poteutial • Potential for Damage • Potential for Significant Damage Disturbance Source • Contact • Vibration • Air Flow • "'ater Friable materials are materials that, when dry, can be crushed, pulverized, or reduced to powder by hand pressure. Prior to snlnpling, these materials are weued with amended water to minimize potential for incidental exposure or accidental fiber release. At the inspector's discretion, personal protective equipment (PPE) is used as an added precaution. Bulk samples are collected using EPA guidelines for the type of suspect material sampled. \\~lCre practical, sample locations are dctcl111ined using random sampling methods. 'Vithin cach arca, samples arc collected where minimal damage will occur 10 facility structures or finishes. A particular suspect malerifll may be found in several different locations within u facility. The EPA does not require that these materials be sampled ill each location, provided the materials are of the SHme type, age, appearance, have the same (hlle of installation, und (lrc sampled in accordance with AHERA requirements to provide statistically reliable dati:! that can be extrapolated onto all remaining non~ sampled areas. EPA/AHEM-accredited inspectors determine the Ilumber of samples of each material to be collected, depending on the material's category and the amount of material present. The objective of the AHERA protocol is to insure statistically reliable data by requiring or suggesting a minimum number or samples to be collected and. in some cases, by requiring the use or random sampling lcclllliques to determine sal111~le locations. However •. in every case, AI-~~RA r~lie~ on the judgmellt of inspectors experic~.:;.e?rln-"\. AHERA methodology and \Vlth the type of facility belllg Illspecled. ;~~{ ~ J.... fl" It' ""'-"" 199m.\' mil ,< S.\'OCW((,S. /11-"rin Limited Asbcstol' SUlYCY Invcn\(ll:'--. 730h \\. 4-fri• ,\\'('., Wheal Ridge. CII/ormll', ( Limited Asheslos Survey 7300 W. 44']' Ave. Wheat Ridge, Colorado 1.3 lVIETIIOD OF LABORATORY ANALYSIS Smnples are analyzed in accordance with AlIERA requirements using the following reference methods: • EPA Interim lvlethod for the Detection of Asbestos in Bulk Insulation SZUllple,!; (EPA 600/M 4-82020, December 1982). • McCrone Research Institute's The Asbestos Particle Atlas. All hulk samples are analyzed using PLM visual area estimation (V AE). Friable materials containing asbestos estimated at less than ten percent by PLM-V AE may be reanalyzed by PLM point counting. Additional treatment and tests Illay be llsed as required to aecurately define composition (i.e., ashing, extractions, and TEM). All bulk sample laboratory reports are verified through an established quality assurance (QA) procedure. Unused p0l1ions of samples are archived for a minimum of six months. 1.4 QUALITY CONTROL PROCEDURES All samples are analyzed by laboratories accredited by the National Voluntary Laboratory Accreditation Program (NVLAP). These laboratories pm1icipate in the NVLAP, as well as the American Industrial Hygiene Association (AII-IA) Bulk Asbestos Sample Quality Assurance Progmm. I-Jiggins and Associates verifies all sample data for accnme), by cross-referencing Field Data Shcets. Chain of Custody FOl1ns, and field notes. 1.5 DETERl'I'IINATJON OF ACM CLASSIFICATION The positive identification of asbestos in a material or product can only be made through laboratory analysis. Visual inspection or common knowledge is not a positive test. The asbestos content of a suspect material is determined by collectiug a bulk sample and having it analyzed b)' PLM. The PLM technique determines the specific type of asbestos present in [he bulk sample alld V AE providcs an estimate of the percentage of asbestos. The EPA National Emission Standards for Hazardous Air T'nllutants (NESHAP) -National Emission Standard for Asbestos (40 CFR Part 61, Subpart M) defines a lion-friable asbestos-containing material as any non-friable material with Hil asbestos content greater than Olle percent as determined by PLM analysis. A friable material estimated to contain less than ten percent asbestos (15 determined by PLIvl~ V AE must be analyzed by PLM point counting and determined to contain les5 than one percent asbestos in order to be considered il non-regulated ACM. ~J...U.!.~ .z.~<_ \ ,;.c-,,~I' '..&>;;---.,n. ... j!I lIiggins awl A.r;.'Wciatt>s, 1/1 .•. Limned Ashe~\();. Survey Illventory -]Jill) \\' 4411, Avt: .. Wheal Ridge. Coit,wdl' ( Limited Ashestos Survey 7300 W. 44'" Ave. . Wheat Ridge, Colorado A clarification memorandum issued by the EPA regarding the NES[-[AP regulation included the following statement: liThe parties legally responsible for a huilding (owner or operator) may take a conservative approach to being regulated by the NESHAP. The responsible party may choose to act as though the bnilding material is an asbestos-containing material (greater than 1%) at any level of asbestos content (evcn less than 1% ashestos). Thns, ifthc analyst detects asbestos in the sample and estimates the Hlllouni to be less than J O~f, by visnal estimation, the parties legally responsible (owner or operator) of the building may (l) elect to assulllc the amount to he l,'feater than I % and treat the material as regulated asbestos-containing material or (2) require verification of the amount by point counting. 11 In consideration of this statement, Higgins and Associates cmd City of 'A'heat Ridge agree tbat, in most cases, suspect material samples containing Jess than ten percent, but more than one percent asbestos as determined by PLlvI-V AE are, for the purpose of this report, considered to be ACl'vl. No distinction will be made between these materials and those classified as AClvI by EPA definition. HOlVever, in some cases, material samples with au asbestos content of one percent or less as determined by PLlvl- V AE are classified as "assumed AClvI" and are so addressed in this rep011. At the discretion of Higgins and Associates or City of \Vheat Ridge, materials either ucollsideredll or "assumed" AC:rvl may he analyzed by PLM point counting to provide a more definitive result regarding the percentage of asbestos content. 1.6 INSPECTION LIiVllTS 1.6.1 Accessihle Areas and Materials All accessible interior spaces and rooms located within the structure and falling within I-riggins and Associates scope of work were inspected for asbestos-containing materials. The facility roof Hnd atlached exterior surfaces of the facility were inspected. Bulk samples of roofs and exterior surfaces are collected only upon request andlor when damage to the substrates can be avoided. Higgin~ and Associates does not inspect underground conduit, electrical systems. or, unless specifically requested to do :.;0, any appurtenances or ahove-ground structures that do not directly supp011 the primary facility. \.6.2 Inaccessible Areas and Mnterials Inaccessible areas not denoted 011 facility drawings (sllch as hidden \\'all and floor chases, HV AC dllct fliggimi aud Aswcia(e.\, III ( ( l.imiict! A:.;hcSlO!' Survc\, 7)00 W. 11411, Ave. . Whc(lt Ridge, Colontd(l Examples include, but arc not limited to, cnclosed plumbing with thermal s,-stem insnlation (TSI) materials or HV AC duct interiors containing insulation, duct seam tape, or ~ealant. Inaccessible nreas that arc denoled 011 facility drawings (such as chases, loeked·off nn.~as, etc.) arc addressed as inaccessible with a cautionary statement to asslime the existence of ACh.f, Some huilding components andlor mechanical systems (such as doors, hoilers, engine/generators, elevator brake systems, spot heaters, radiators, etc.) may lwve suspect malCI'ialf> which arc not accessible for sampling. Examples include, hut arc 110t limited to, fire door insulation, interior boiler insulation, gaskets, elevator bmke shocs, and materials beneath substrates. These materials are (reated as ashcstos·containing and are addressed ns such in the recommendations sections. 2.1 INTRODlJCTION SECTION 2,0 ASBESTOS LOCATION SUMMARY This section discusses inspection findings ami analytical results for suspect asbestos-containing malcrial :mmplcd HI the facility located at 7300 \V. 44th Ave., "'heat Ridge, Colorado. Higgins conducted an inspection as outlined in the scope of work detennilled hy City of Wheat Ridge. The potential for asbestos fiber release and recommendations for future action are presented for all ACI\1 identified (refer to the "Recommendations" sub-section for Ihe building). Representative samples of suspect materials were sent to an accredited laboratory for analysis. Appendices for this repOIi arc as foil Oil'S: • Appendix A -Glossary --list of terms used in this report • Appendix B -L"horalor)" Resnlts --bulk sample analyses results • Appendix C -Inspector Cerlif"ication • Appendix D -ACM Location Drawing 2.1.1 Statement of In,,cccssi\)i1i1~' During tht' site visit, enclosed pipe chases were inaccessible for inspection. Higgins and Associates helieves that the materials most likely to exisl in these arcas were not identified in other areas of the 1~lCility and determined to be ACrvl. Unidentified suspect materials encountered in inaccessible areas dUrillg future repair. renovation, or demolition projects should be assumed asbestos-containing until smnpJc collection nnd subsequent analysis prove otherwise. lIiggill.\· awl :\'\'sol'ia/('s, /II ( ( Limited Asbc~lo!' Survey 7301111'. ",,'" JIve. Wheat Ridge, Colorado 2.2 INSPECTION DATE AND INSPECTOR INFOHMATION The 7300 W. 4<1'" Ave. facility was inspected on April 12. 2010 by Mr. Michael Semonisck and Mr. Michael Hartman of Higgins and Associates. Mr. Scmonisck and Mr. Hartman are EPAIAHERA trained lind accredited Colomdo State asbestos inspcetors. 2.3 FACILITY INFORMATION The 7300 W.44'" Avc. facility consists of one fioor (gas station with 2 garage bays) and tilt' original date or construclion was reported Lo be unknown. The huilding rOllndnlion and exterior walls are constructed of concrete. brick, and cinder block. The intcrior iinishes includc (lJ)'lI'all. linoleum fioor tile. sheet linoleum Oom-jng, plaster, and calJlcting. The roofing system of the facility was sampled, The HVAC unit is located iusidc orthe facility. 2.4 7300 W. 44'h AYe. Facility 2.4.1 Suspect Material SlIIlll1lary The following suspect material was ideutified: • • Drywall and associated Joint Compound Cove Base (white) and associated Adhesive • Cove Base (gray) and associated Adhesive • 12 in x 12 in Linoleum Floor Tile and associated JVlastic (2 types) • Sheet Linoleum Flooring (yellow pebble pattern) • CMU Surfacing Texture (2 types interior/exterior) • Window Glaze • Wall Plaster • Brick and associated Mortar • Composite Rooling Material • Roofing Seam Sealant (black) • Roof Brick Caulking (white) • Roof Drain \Vrap • Garage floor COaling 2.4.2 Ashestos-Containing Material The following AeM was identified at the 7300 W. 44'" Ave. facility. Unless otherwise noted. the materials were in good condition at the time of inspection: • Drywnll Joint Compound: Located at the ceiling spa<.:c in the garage arCH contains approximnlcJy 2-30;(, chrysotiJc asbestos. The HPPl'oximalc quantity IS ,,)y,J--U4\.: estimated to he 1.400 sqUaJ e feel in good condition. t~~:~ ",,_A lIiggim (l1U1 A Hocial('!i. III (.,,,., Linlitcd A~besto~ Survey 7300 \Y. 44" Ave. Wheat Ridge. Colorado • Sheet LinoleulIl Flooring: Localed undemeath the linoleum floor tile in Ihe garage bath eontains approximately 30% chrysotile asbestos. The approximme quantily is 30 square feci in good condition. • Flooring Mastic (hlaclt): Located inlhe office balh undernealh linoleum Uoor tile contains approximate1y 4% chrysotile asbestos. The approximate qmmtity is 25 square feel in good condition. • Fire Doors (nssnllled ACM): Two doors localed al Ihe rear comers of the garage area, 2.5 RECOMMENDATIONS Higbrins and Associates recommends the development and implemeutation of an Operations and Maintenance Prograrn specific to the 7300 W. 44"' Ave. faeilit)' located in Wheat Ridge, Colorado. The principal objective of an O&M Pro!,"'am is to minimize exposure of all building occupants to asbestos fihers. To accomplish tlus objective, an O&1'vl Program includes work practices designed 10 assist in (I) maintaining ACM in good ('ondition, (2) enstlling proper cleanup of asbestos fibers previously released, (3) preventing further rclease of asbestos fibers, amI (4) monitoring the condition of ACM. The specified O&M work practices and procedures should be employed by tmined perwnnel during building, cleaning, maintenance, renovation, and general operational activities thalmay involve surt:1cing, thermal, or miscellaneous ACM. To achieve its objectives, a successful O&M Program should includc the following clements: • Notificntion: Develop a prOb'Tam to teB workers, vls11ors. and building occupants where ACM is located, and how and why to avoid disturbing the ACM. All persons affectcd should be properly infol1lled and all friable AeM should be properly labeled . ., Surveillnnce: Conduct regular ACl'll surveillance Hlld re-inspection to note, assess, amI document any condition changes in the ACM . ., Controls: Implcl1lcn! a work cOlltrol/pclnlit system to control activities which nught disturb ACM. • WOl'l( l)l'lIc1ices: Establish O&M work practices to avoid or minimize tiber release during activities affecting ACt'll. • Heconl Kceping: Document O&M activities. Limited A~hes!o.~ Sur\'('Y In\'(,IIIOI), -73Of, \\' 4-311' A\'e .. Whe,]! RiJg~, Colm.ItJ(l lfigg;II.\' lIml As,wJciules. III Limited Ashestos Survcv 7300 \1'. 44'" Ave. . Wheat Ridge, Colomdo o \Voricer llrotcction! Develop medical and respimtory protection programs, as applicable. o Training: Establish a Facility Asbestos Coordinator, and provide custodial and maintenance staff tmining. • Emergency Procedures: implement proper emergcncy response procedures. • AirI\'1onitoring: Track and monitor health concerns and action levels. The following are rcconunendations for ACIvI identified at this facility. 1vlaterials assumed asbeSlOS- containing should be sampled by trained personnel and analyzcd by an accredited laboratory prior (0 removal or alteration. Unless planned demolition, renovations, repairs, damaged ACM, or the potential for damage require such actions, it is recolllmended that the ACM identified in this report not be disturbed or removed. If the ACM lllust be disturbed or removed for an)' reason, personal protective e(luipment and properly trained personnel must be utilized. Altemtions to or the removal of asbestos- containing materials requires adherence to all applicable federal~ state. and local regulations concerning the removal and disposal of asbestos materials. Periodic condition inspections arc recommended until the materials are removed. 2.5.1 Friable Asbestos-Containing Material Sheet Linoleum Flooring is classified as friable material. These materials should never be torn, ripped, cut, or penetraled for any reason without following appropriate local, slate, and federal regulations concerning asbestos removal and disposal. Care should be exercised when accessing arCHS containing linoleum. Contact with the materials may cause damage and the release of airborne asbestos fibers. 2.5,2 Non-Friable ASbestos-Containing Material Drywall joint compound is classified as non·friahlc ill H finished Hnd painted state. Penetrations of these materials will calise them to become friable. Abrasive actions sHch as sanding, drming~ cutting, etc. should be prohibited ulliess proper precautions are observed. Flooring i\1nstics are classified as non-friable unless Lhey have become dry ami brittle from age. heat, air, ctc. Abrasive actions slich as cutting, drilling, sanding, etc. may also cause the materials to become friable and should not be performed unless proper precautions are followed. These materials are generally used as adhesives and applied 10 fiooring materials. !-I;ggill.'I ami Associates, //(" Limited Asilc51(l" Survcy hlVcllwry -7]()fJ W 44,j> Ave.. Whem Ridge. CoIOladt', Limited Asbestos SUlve\' 7300 W, /flllh Ave, . Wheat Ridge. Colorado Fire doors arc classified as llon-friHble as long a~ the veneer of the doors remains intact and undisturbed, The insulation located nt the core of a fire door is classified HS friable. If the d(Jor veneer is cut, drilled, or penetrated in any manner, asbestos libel's could he released. Fire doors are normally identified by the fire-rating lahcl~ adhered to (he doors. Because tlw labels are not alwAYs present, :mmc fire doors may not be identified. The fire doors in this IllCility were not sampled to avoid administering damage and arc assumed to be asbcstofH:ontaining. Therefore, prior to cutting, drilling, or in any wny penetrating nil)' of these doors! the insulation should he sampled and analyzed for asbestos content. 2.6 LIMITATIONS This report describes the locations and conditions of ACM identilied at the 7300 W. 44'" Ave. facility locntcd in \Vheat Ridge, Colorado at the time of inspection. Higgins and Associates represents that our services nre performed within the limits prescribed by applicable regulations nnd in a mnnner consistent with the level of care and skill ordinarily exercised by other professional consultants undcr similar circumstances. No other representation is made 10 the client, expressed or implied, and no warrnnty or !,.lltarnntec is included or intended. Michael Semonisck iVlanagcr of Asbestos Asscs:mlcnts ~~~v Reviewed By: Al1 Goguen Director of EllS ( Limiled Asbestos SlIIVC" 730Cl W. 4<111, Ave. . Whenl Ridge. Colorado Appendix A Glossa",I' J-/iggills llJUi.·ls.Wlc;ah',\", If~ ( GLOSSARY Actinolite -one of six naturally occurring asbestos minerals. It is not Ilormully used commercially. Action levcl-a level of airborne fibers specified by OSHA as a warning or alert level. It is O. I fibers pCI' cubic centimeter (lice) of air, 8-hour lime-weighted averagc, as measured by phase contract microscopy. A ImRA -Asbestos Hazard Emergence Response Act. AlBA -American Industrial Hygienists' Association. A ll10site -(brown asbestos) an asbestos form mineral of the amphibole group. It is the second 1110st commonly used form of asbestos in the U.S. Amphibole -one of the two major groUJlS of minerals fiOln which the asbestos form minerals are derived -distinguished by their chain-like crystal structurc and chemical composition. Amosile and crocidolitc are examples of amphibole minerals. Anthophyllite -one of six naturally occurring asbestos minerals. It IS of limited commercial value. Ashestos -a generic name given to a number of naturally occurring hydrated mineral silicatcs that possess a unique crystalline structure, are incombustible in air, and are separable into fibers. Asbestos includes the asbestos [Ol1n varieties of chrysotilc (serpentine), croeidolite ( rieheckite), amosite (cllllllningtonite-grunerite), anthophyllite, actinolite, and tremoiite. Ashestos-Containing Material (ACM) -any material or product which contains more than I percent of asbestos (AHERA dcfinition). Ashestosis -sCa!l'ing of the lungs caused by exposurc to asbestos. Continucd exposure may lead to degeneration of lung function and death. Bulk Sample -samples of bulk material; in the case of asbestos, suspectmatcrial. Carcinoma -a malignant tumor of epithelial origin, and in this context, referring to membranous tissues of the human hody. Chain-or-custody -formal procedures for tracking samples and insuring their integrity. Chl'l'sotil(' -(white asbestos) the only asbestos form mineral of the scrpentine group. It is the most comlJlon form of asbestos used in buildings. Crocidolitc -(blue asbcstos) strongest of asbestos minerals. As asbcstos form mineral of the amphibole group. It is of minor commcrcial value in the U.S. EPA -Environmental Protection Agency. Epidemiology -the study of causes, occurrence and distribution of disease throughout a popUlation. Firc(lJ'oofing -spray or trowcl applied firc resistant matcrials. Friable -muterial that can be crumbled or reduced to powder by hand pressure. Functional spaces -spatially distinct units within a building whieh contain identifiable populations of building occupants. Heating vcntilation. and air' conditioning (HVAC) systcm -the system of pipes. ducts. and equipment (air conditioner, chiller, heaters, boilers, pumps, lim's) uscd to heat. cool, movc, und filter air in a building. HVAC systems are also know as mechanical systems. Homogencous areas -an area which appears similar throughout in terms of color, texture, and date of material application. Lung cancel' -a malignant h'fOwth of tissue in thc lungs, specifically of the bronchial covering. Mcsothelioma -a rare cancer ofthe lining around the lung or the abdomen. MesothcliUIIl -epithelium derived fi'om mesoderm that lines the boely ca\'ity H vortcbrate embryo and gives rise to epithelia, among others. NESHAP -National Emission Standards lor Hazardous Air Pollutants. NVLAP -National Voluntary Laboratory Accreditation Program. J'crsoll81 Protcctive Equipmcnt (PPE) -equipment, such as hard-toe shoes, gloves, respirator, otc. designed to protect II workcr from certain work place hazards. Phase Contr'ast Microscopv (PCiV1) -a method of analyzing air samples for fibers using a light microscope. Polarized Light iVIicroscopl' (PLlVl) -11 mcthod of analyzing bulk samples for asbestos in which the sample is illuminated with polarized light lIight which vibrates in only one plane) and viewed under a light microscope. Quality assurance -a program for collecting and analyzing sllspect material to check on the liability of procedures. additional duplicate of IJigg;lls awl As.wu';ales. II! { Regulated material -in the eHoC of Act,,!. a material io regulated by federal law if the asbestos coutent is one percent or greater by volume. Rcspil'aton' tract -the organs of the body which convey mr to the blood, allow exchange of gases, and remove carbon dioxide. Serpeutiue -one of the two major [.(roups of minerals /i'om which the asoestoo form minerals are derive -distinguished by their tublliur otl'llcture in chemical composition. Chrysotilc io a serpentine mineral. Surfacing material -material in II building that is spray-on, troweled-on, or other wise to smfaccs, such as acoustical plastcr on ceiling and fire proofing materials on structural members, or other material on smlllce for acoustical, fire proofing, or other purposes ( MIERA definition). Svnergistic -the combination of to efTects which is greater than the oUIl1 of the two independent effects. Thermal Svstem IIlSlllatioll (TSl) -means material applied to pipe, littings, boilers, breaching, tanks, ducts, or other interior structural components to prevent heat loses or gain, or water condensation, or for other purposes. Transite -a trade name cOll1monly lIsed for asbestos cement wallboard and pIpe material. Transmission Electron JVIicroscoj)" cn:iVJ) -a method of analyzing air samples for asbestos libel'S lIsing a transmission electron microscope and, possibly, associated instrullIcnts for further identifying asbestos. Tl'cllIolite -one of six nat11rally occurring asbcstos minerals. Trcmolite has few cOlllmercialuses. Vinyl Asbestos Tile (VAT) -a floor tile made of plastic imbedded with asbestos. ( ( Limited Asbestos Survey 7300 W. 4111h Ave. . Whem Ridge. Colontdo Appendix B Lnhol'Rtol'Y Results ( EMSL Analytical, Inc. 7330 S. Alton Way Building 12 Sulle A. Centennial. CO 80112 Alto: Fax; Project: Phon(!: (303) 7.IQ·!l7ClQ ,. Mike Sell10nlsck Higgins & Associates, LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 706·9M6 Phone: City of Wheat Rldgo Customer 10: HIGG78 CustCfncr po: Received: 04112/102,00 PM EMSLOrder: 221000541 (303) 708·9646 EMSL Proj: Analysis Dale: 4/1212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Sample Description W·l·A-FIOOf TUe 12x12 linoleum liIe 2210005-lfijjQl W·l·A·Maslfc 12x12lfnoteum We 22100Q54I.fJOO IA W·l·B·FIOQ( Tile 12x12Hnoleumlile 22f00054f..()O()2 W·I·B·Maslic 12x12l1nofeum tile nlOl)Q$l r-OoJOlA W·l·C-Floor Tile 12x 121inofeum lile 2211A~I.(j()1)J W·l·C·MasUc 1 12x1211nofeum lile 22100054I.fJOOJA W-l-C·MasUc 2 12xl2l!nolc-um lile UlfXiQ5H..QOO38 Analyst(s) Erin Ort/JUt} (64) DeCaval/as Michael (20) Polarized Light Microscopy t:{oo"As!2cslos Appearance % Fibrous Beige Non-Fibrous Homogeneous Clear Non·Fibrous Homogeneous Beige Noo·fjbrous Homogeneous Crear Non-Fibrous Homogeneous Beige Non-Fibrous Homogeneous Clear Non-Fibrous Homogeneous Black Non-Fibrous HonlOgenoous Asbostos % Non·Fibrous % Typo 100% Non-fibrous (other) Nono Detected 100% Non-fibrous (other) Nona Detected 100% Non·fibrous (athel) None Detected 100% Non·fibrous (other) Nono Delectod 100% Non·fibrous (other) None Detected 100% Non-fibrous (other) None Dotected 96% Non·flbrous {other) 4% ChrysoUle Erin Orthun, laboratory Manager Of other approved slgnalOf)' (}J9 to magrufcab«l !.mitat«ls inherent;n PlM. asbestos r,beiS In QifNln~«lS be!o ..... t.he resolut;oo capabi!,~/ of PLY mayflO!. 00 detected. The limit of de\&tic-fl as sta!M mlho method is 1%. The ab<l,i\! t6~1 repo.1 reta\&S ooly to the itemslestoo and may /'101 be reptoducM In a/'l~ fOfm without \he e)pess 'Millen apPfufill of EMSl An3lfo<:al. Ir<;. EI,ISl's liabol,I/!S limited 10 the cosl .of al"alySls. EI,ISl bears flO respons.ibolily f« sampo cO:!«~on acth~tles Of analytical method lim;tations. l"llelprela(oo and use 001 test Ie:5U1s ale tho resporIsibil,ly 001 tho clienl Sampfes f&<:J:Hve4 In good ccn';Hon unless o'tler.>lise 11¢led. This fOPQ{1 ml.lst not be used 10 claim produ<.t endersemOl"lI by tM.AP or any agEtlC)' or tho u.s. G;iloemmenl Samp!e$ ana~ed by EMSl Anal1ic:al, frle. 1130 s. Allco Way Bvi!,fflg 12 SUllO A. CetlleM1J!CO Test Repe<! PLM·7.12.0 Printed: 411212010 6:45,04 PM ( EMSL Analytical, Inc. • 7330 S. Alton Way Building 12 Suite A. Centenniai. CO 80112 Phone: (3{))) 7~j).5700 Fax: (303) 7.t1·UOO Emilil: den'lNlilIY'i.~fflsl CQm .j Alln: Mike Semonlsck Customer 10: HIGG78 Higgins & Associates, LLC Customer po: 8200 South Akron Street Received: 04/121102:00 PM Suite 117 EMSL Order; 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phone: (303) 708·9846 EMSl Prcj: Project City of Wheat Ridge Analysis Date: 4/1212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Samplo Description W·2·A·Floor Tile 12x12 linoleum tile 221()(}(}54I·00M W·2-A-Masllc 12x12 linoleum lila 2210005.fl-0004A W-2·B·Floor Tile 12x12 Unoleum lire 221000541-0005 W-2-B·Mastic 12x12 linoleum tile 221ooo54I.oooSA W-2-C·Floor Tile 12x12 Hncleum tile 2210005-l1-{KJ()6 W-2-C·Masllc 12x12 linoleum me 12fOOO54t.ooG6A W·3·A sheet linoleum 22fOOO5-1t.()OQ1 yellow pebble Analysl(s) Erin Ortllun (64) DoCavalJas MIG/wei (20) Appearance % G,"I Non·Fibrous Homogeneous Clear Non·Fibrous Homogeneous G,"I Non·Fibrous Homogeneous Clear Non·Fibrous Homogeneous G,"I Non-Fibrous Homogeneous Clear Non·Fibrous Homogeneous Yell"", Fibrous Hetercgeneous ~on.Asbestos Fibrous % Non·Flbrous 100% Non·fjbrous (other) 100% Non-fibrous (other) 100% Non·fibrous (other) 100% Non·flbrous (other) 100% Noo·fjbrous (other) 100% Non·fibrous (other) 70% Non·fibrous (olhef) Asbestos % Type None Detected None Detected None Detected None Detected None Detected None Detected 30% Chrysotlle Erin Orthun, LaboralOf'j Manager or othef approved signalOf)' Due to magni'i<;ation J"rhtal'ons inh~ren! in PlM, asbutes f.ti"rs in <lim(lnZions be!G'1{ 1M reso!ul'<>n. c.lpabM, of PlM may not be oetfrtteo. The I'm'l of detecticfI as sl~~ed in the method is 1%. The abo\-I) tul report relates on1y to \,he items tesloo and may nol to reproduc()<j in any form \\ithoul the 6'J)ress written appro'tal of EMSLAncJj't"-cal,~. EMSL·s tiabir.tyis limited to the cool of anal)"5is. EMSl bears f'K) tM£H)fISlt)llfy fa! sample c11leclion act;I.!ies or analytical me1}lod IimltatiOllS. h!ErpretaliM and use of tast re:suas are the resPQllslbi~ty(;f the (;r;enl Samp!es fe<:eh~d in good cCfldj~OI\ un'ess olherMse noted. This report must not be usro 10 cJalm pr04lJ(! eMOf$emefll by tM.AP ot arq agEdtGy of the U.S. Golemmenl Samples anal)'leQ by EMSl AnaljicaJ, t'1~. 7331) S. AltM Way &.llldirlq 12 SOlie A. Cefltefl()ia!CO Test Report PlM-7.12.0 Printed: 4112/2010 6:45:05 PM 2 ( EMSL Analytical, Inc. • 7330 S. Alton Way Building 12 Suite A, Centennial. CO 80112 Phone: (03) 7,10·5700 FaA: (303)741.1.100 Email: donvcIIab.i:i\.m;;l.com AUn: Mike Semonlsck Customer 10: HtGG76 Higgins & Associates, LLC Customer po: 8200 South Akron Street Received: 041121102:00 PM Suite 117 H,'SlOrder: 221000541 Centennial, CO 80112 Fax: (303) 708-9646 Phone: (303) 706·9846 EMSL Proj: Projecl: City of Wheat Ridge Analysis Dale: 4/1212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample W·3·B 221000541-0008 W·3·C 221000541-0009 W-4·A·FlOOfing 221ooo5.fI-OOIO W ·4-A-Compound 22fOOO54f.{)(}fOA W·4·B·Ftooring 221000541-0011 W·4·B·Co(npoond 22fOOO541.Q1)IIA W-4-C-Flooring 221000s.f1-M12 Analysl(S) Description sheellJnoIeum yenow pebble sheet linoleum yeUO'o'/ pebble White (loOOn9 While flooring While 1l000ing While flooring White flooring Erin Ort/wn (64) OeCavallas Mlcllael (20) Non·Asbestos Appearance % FIbrous GraylVVhite Non· Fibrous Homogeneous White Non-Fibrous Homogeneous GraylWhite Non·Fibrous Homogeneoos White Non·Fibrous Homogeneous GrftojI'Nhite Non·Flbrous Honlogeneoos % Non-Fibrous 100% Non·fibrous (other) 100% Non-fibrous (other) 100% Non·fibrous (other) 100% Non·fibrous (other) 100% Non·fibrous (othel) Asbestos % Type Stop Positive {Not Analyzed} Stop Positive (Not Analyzed) None Detected None Detected None Detected None Dotected None Detected E(in Orthun, labofatory Manager 0( olher approved signatory Due to magnJicalion limitatioos Inherent in PlM. asbus!os flb(lrs In Q.fT1ensiOO$ belOW ttle fe-So/llt'O!! (.;pabi!,t)' of Pl).,l ma), nol be detected. The bmit of de1e(tion as sla:e:i in the method Is 1%. The aoo'9 leslrepo.1 relates ()<It)' to tM i1ams lesh;d and ma), roct be repfod<.:ced in any rann witJ,oOt.Il the e-q;ress ...... ritlen appro~al 01 El-,l,SlAna.'yt"cal.~. EMSL·s liabitil)' is limited to lI1e cost of analysis. EMSl beals flO fe.sp!)l"'Sil:i1i~ fOl samtJe col!&et"on .l(II,ire.s Of ana~cal method EmilatilJ(ls. \"lterprelalion and lise ortesl fG3t.1lt;, are the responsibility of the elienl Samples fQCeive-d III good coodi!.'oo unless o11er.'ilse noted. This Ie-poet mllsl not be lIse<;l 10 claIm plodu<:t endCfSemen\ by NVlAPOI arr/ .lgt!flcyoft/1e U.S. Government Samples anatned by EMSL Ma!)tic.a1. \"leo 7130 s. A1tvn Way B<iifd;fig 12 Suite A. CentennialCQ Test Repcrt PlM-7.12.0 Printed: 4/1212010 6:45:07 PM 3 EMSL Analytical, Inc. • 7JJO S. Alton Way Building 12 SuUo A. Centennial. CO 80112 f'horl~: (303) HO·S700 I.-Fax: POl) 7011·1400 Email: d;:oyCflilb'i1\7!msl.CQ/Jl .1 AUn; Mike Semonlsck Customer 10: HIGG78 Higgins & Associates, LLC CustOillerPO: 8200 South Akron Street Received: 04112110 2:00 PM Suite 117 EMSL Order; 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phone: (303) 708·9846 EMSL Proj: Project: City of Wheat Ridge Analysis Dale: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample Description W-4-C·Compound White flooring 12looo54/.oo12A W·5·A 2210005-11-001) W·5·B 22/iXXXi41-QOf4 W·5·C n1V00541..(JQ15 W·6·A 22 lQ0/')54 1.00'6 W·6·B 221(1'.t05-41.oo17 W·6·C 22fOOQ~,..oo18 Ana~sl(s) Window glaze WindON glaze W!ndcr.'l glaze CMU Texture (dd) CMU Texture (dd) eMU Texture (dd) Erin OrllllllJ (64) OaCavaltas Michael (20) Appearance Whfte Non· Fibrous Homogeneous Tan/White Non·Fibrous Heterogeneous TamWhite Non-Fibrous Heterogeneous GrayfTan Fibrous Heterogeneous GraylWhlte Non-Fibrous Heterogeneous GrayJWhite Non-Fibrous Heterogeneous GrayfWhlte Non·Fibrous Heterogeneous Non·Asbestos % Fibrous 3% Fibrous (other) % Non·Fibrous 100% Non·rlbrous (other) 100% Non-fibrous (other) 100% Non-fibrous (other) 97% Non-fibrous (Olllet") 100% Non-fibrous (other) 100% Non-fibrous (other) 100% Non-fibrous (other) Asbestos % Type None Dotected None Detected None Detected None Detected Nono Detected None Detected None Detected Erin Orthun, laboratory Manager Of other approved signatory DlJe to magnification ~mita~C()s inherent ill PlM. asbestos ~ber$ln dirrd/nS:OIlS be!o'll tha resolufoo capab,J;tJ of PlM may net be detected. The limit of detection as sialed in the method is 1%. The abo\-e te-s! repOfl retates O(IIy to the items \M\OO ancl may tlCt be reproducetj io any form .... i\hovl the 'hpress written apptovat of EMSl AI'la1~ticat, Inc. EMSl's liabl'ilyis timi(1:td to the cost of analysis. EMSl bears 110 res.POl",!J~j;tl ~ sample col'&etion acti>itics Of ana1)'\ical me!.hoo t'mitations. nterpletatioo and use of test resu\l~ are tha respOflSlbi!ityof the c.lienl Samples fece;~ in 900'1 wndftiOfl u,'Il6ss otleMise noted. This re~ortmus! nco! be used to claim prooUCI efldGtsemel1t by NYlAP or any agencyoft/1e U.S. Go\~nm6I1L Samp!es analyzed b' EMSl An3t~'\ical, Inc. 13-30 S. Aiton Way Bwlding 12 Suite A, CentennJalCO Tesl Rep«! PLM·7.12.0 Prlnled: 4112120106:45:08 PM 4 EMSL Analytical, Inc. • 7330 S. Alton Way Blillding 12 Sliite A. Centennial. CO 00112 PllOrH~! (303) 7,10·5700 I- F,lX; (303) 741·1,(011 Emilll: dCIlYellait{i<1fJ)sl COIll Altn: Mike Semonlsck Customer 10: HIGG78 Higgins & Associates, LLC Customer po: 8200 South Akron Street Received: 04/121102:00 PM Suite 117 EMSlOrder: 221000541 Centennial, CO 80112 Fax: (303) 708·9848 Phone: (303) 708·9846 EMSL Proj: Project: City of Wheat Ridge Analysis Date: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method lIslng Polarized Light Microscopy Samplo Doscrlptlon W·7·A eMU TextUre (new) 21100054 t.O!J t 'J W·7·B eMU Texture (new) 12lfXlO>jl"()()20 W·7·C eMU Texture (new) 22/ooo54f..Q021 W-8·A-Cove Base Cove base (""nite) 221()i)()5.ft-oQU W·8·A-Mast!c Cove base (\\tJite) 22IQOO541.(J()22A W -8-B-Cove Base Cove base (white) 22100054 f-()QZJ W -8-S-Mastic Cove base (vmile) 22II)()1J5.fI.oolJA Analyst(s) Erin OrlhulJ (601) DeCavallas Mlcll8el (20) Appearance % GrayNihite Non-fibrous Heterogeneous GraylWMe Non·Fib(cus Helcfogeneous GrajlWtile Non-Fibrous Heterogeneous White Non-Fibrous HOOlogeneous Ye!IC1N Non-Fibrous Homogeneous While Non-Fibrous Homogeneous Yello .... Non-Fibrous Homogeneous Non·Asbos!os Fibrous % Non·Flbrous 100% Non-fibrous (oUler) 100%. Non-fibrous (other) 100'% Non·fibrous (other) 100% Non-fibrous (other) 100% Non-fibrous (othe() 100% Non-fibrous (other) 100% Non-fibrous (other) Asbestos % Type Nona Detected None Detected None Detected None Detected None Detected Nona Detected None Detected Erin Orthun. labocatory Manager Of other approved signatory Due 10 magnlficatioo l;m;la~o(ls Inherent in pu.t asbestos r'bg,S i(l d:menSiOM baio ..... lhe resQllltiOll c<!patM, of PU.C may not be .:Ietaclad. The fJmil 01 d&lectiCofl as stated in the method is 1%._ The abole test report relales onlylo the items tested and may net be fep:od'ucM in aflY fOfm .... ill'.ol.ll the e)press .... llI\en a~~o'.'31 of E/"\SLAnal)lcal. Ir--=. EMSL's Habi!j~1 is limited to the cost of analYS;5. EMSl bears nOfe.sponsibl,ly fOf sample co'te<:tioo at:iIiFe.s Of anal:!,lical methcd IimitatiOM. ~!efple!a~on and use of !e~! results are the r6Spcosit-il·tyof the clieot Samples ,ocei\oo in g.ood CGr1d;~vo unless o't1er .... ise r.G\ed. This (eport muSlnol be used to claim prod~ct onOOf"semel1\ by tNLAP or al1"/ ageoc"/of V:e U.S. Go·,'Srnmel1l. SamplGS analyzed by EMSt A'lal tical, nco 1.)30 S. Nlc'" Wa'! S.fkl''"''l 12 SuitEl A, Cen!ennialCO Test Report PlM-7.12.0 Printed: 4/1212010 6:45:09 PM 5 ( EMSL Analytical, Inc. 7330 S. Alton Way BlIildlng 12 Suite A. Centennial. CO 80112 Photll': 7>11·1400 Ern,,}I: AUn: Mike Semonlsck Customer 10: HIGG78 Higgins & Associates, LLC Customer po: 8200 South Akron Street Received; 04/121102:00 PM Suite 117 EMSL Order: 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phooe: (303) 708·9846 EMSL Proj: Project: City of Wheal Ridge Analysis Date: 4/1212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Polarized Light Microscopy Sample Description W -8-C·Cove Base Cove base (vAlile) 22'000541.(;(124 W-8-C·MasUc Cove base (v.hite) 'l2rOOO54t-OOUA W·9·A·Cove Base Cove base (gray) 22f()(l()5.ff.()/)25 W-9-A-MasHc Cove base (gray) 221orJOS41..oo2M W·9-B-Cove Base Cove base (gray) 22fOOO~I.oo~6 W -9-B·Mastic Cove base (gray) 2210005ff.oo26A W -g·C·Cove Base Cove base (gray) 22 fl)(X)54 1-0027 AnalySl(S) Erin Od/lUn (64) OeCavallas Micllael (20) Appearance % White Non·Fibrous Homogeneous yelto .... Non-Fibrous Homogeneous Gr", Non·Rbrous Homogeneous Tan Non-Fibrous Homogeneous Gr", Non-fibrous Heterogeneous Tan Non·fibrous Homogeneous Gr", Non·Fibrous Homogeneous ~on·Asbostos Fibrous % Non·Flbrous 100% Non'fibro!l$ (other) 100% Non·fibrous (othel) 100% Non-fibrous (olher) 100% Non-fibrous (oUter) 100% Non· fibrous (other) 100% Non·fibrous (other) 100% Non·fibrous (othef) . , Asbestos % Typo None Detected None Detected None Detected None Detected None Detectod None Detected None Detected Erin Orthun, LaboralOf}' Manager or other approved signatory DtJe 10 magn;lie.ation ';mila~OI1S inherent in PlM, ascest05 {,bers in o;mens'OflS beler .... the lesolution t.ap(lb,lrtyof PlM may not be deteet~. The lim,! cf oete<tion as slaled ,n the method Is 1%. The above test repoi! ,elates ooly 10 the items testoo and may nol be rep:"01ueeJ In any roon .... 'IhQIl! the elpress writlen app1ol'al of EMSl Anal:rftal,~. EMSl's UabiMy Is tlmlted to the cosl of an~'~ls. EMSl bears nt;llesponSibdily fur samf~e co'!etticf1 acti,l!ies Of <lllaly'Jcal method limitatio!"lS. hte(pfeta~on and lise of lest resu:ts are the respoosibili!yofthe t!'en\. Samples flKeh-ed in gcOO (;¢n6itioo unless oliler.\ise noted. This (6pcrt must notbe usQ-j 10 claim prodIKI endors6ment by NVtAP or any asencyofthl.l U.S. Gol-emmenl Samples analVledb EMSlAnaly.;cal,l1c. 1330 S. N:Of1Wav fhtd:ng 12 SuiteA. Centennia:CO Test Repcrt PLM-7.12.0 Printed: 411212010 6:45: 10 PM 6 EMSL Analytical, Inc. • 7330 S. Alton Way Building 12 Suite A. Contennlal. CO 80112 AUn: Fax: Project: Phon~: (30) 7·'0·5700 i· , Mlko SOll1onlsck Higgins & Associates, LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 708·9848 Phooe: City of Wheat Ridge ., Cust()(ner 10: HIGG78 customer po: Received: 041121102:00 PM EMSlOrder; 221000541 (303) 708·980\6 EMSl Pro!: Analysis Date: 411212010 Test Report: Asbestos Analysis of Buill Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample Doscrlpllon Appearance W -9·C-Mastlc 2l1000~"..{I(JllA Cove base (gray) Tan W·l0·A·Jolnt Compound 221{)f'''()S4t.oo28 W·10·A·Dlj\'Iall 221000:.41-002&01. W·l0·B·Joint Compound 2210<)0541.(.01)29 W·10·B·Dry.'Iall 22ICOO5-1I..()Q2IJA W·10·C·Joinl Compound 1210005.fI-OQ'w Analyst(s) DW/JC Baths OW/JC Baths DW/JC Balhs DW/JC Balhs OW/JC Baths Erin Orthllfl (64) DoCavalfas Mich,llJl (20) Non-Fibrous Homogeneous Whije Non-Fibrous Homogeneous BrOYt'fllWhilo Fibrous Heterogeneous WMe Non·Fibrous Homogeneous BrownNJhlte Fibrous Heterogeneous Wh~e Non·Fibrous Homogeneous Non·Asbestos % Fibrous 10"10 Cellulose 10% Cellulose % Non·Flbrous 100% Non·fibrous (other) 100% Non·flbrous (olher) 90% Non-fibrous (other) 100% Non-fibrous (olher) 900/" Non·fibrous (olher) 100% Non·fibrous (olher) Asbestos % Typo None Dotected None Detected None oetocted Nono Dotected None Dctect~d None Detected Erin Orthun, labocalory Manager or other approved signatory Due 10 mag";~c.atioo j;rnila~Otls onhQr<e1\1 in PlM. asbestos (,I.lm. in d mensiof1S be!G>H the re1cll;t<C<'! capao,f,1y of PlM may not be de!e<;too. The r:mi\ of detecMn as ~Ia!oo In the met/"lOO Is 1%. The abo\>3 test lepoo relato.s or:ly 10 the Il¥Os testoo and ma"! 1\1)1 be rePfo-j<.tCe(j In any ro;m \V,I/lCQ\ the e'pless wtitlen aH~o·,-a1 (if EMSl AtIaJy«31, h:. EMSl's liabil;ty is l:mittXIlo the cosl of analjSis. EMSL bears 1\0 r6spOM.io.li~ rt;( sam~la col!ec~on aGtilities!)l" ana~,ti(al method Emibtions. htelprel..l!i!)(l and U$(I of IllS! rOSlilS afl1lM re.5pot"1Slbittyof Lhll (tenl. Samples lecehe<j III ~ con,HiOli ul\iess ofler,o,ise notGd. This lef,«! must not be used to Claim prlXfuc! endorsement bl tM./IP or ant 3gencyof 1M U.S. Gl\~rnment. Sa",pre~ allaiyz.ed by EMSl Anat~t;c3!. t1c. 13)0 S. Mon Way &i!d"ng 12 Suite A, CentemlJaiCO Test Repm PlM·7.12.0 Ponied: 4/1212010 6:45:11 PM 7 ( EMSL Analytical, Inc. 7330 S. Alton Way Building 12 Suit" A. CO"lennl"1. CO 80 112 Alln: Fax: Plojecl: "hom>: (303) 7,10·5700 .' Mike Semonisck Higgins & Associates, LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 708-98·18 Phooo: City of Wheat Rldgo Customer 10: HIGG78 Customer po: Received: 04112110 2,00 PM EMSL Order: 221000541 (303) 708·0846 EMSl Prc1: Analysis Date: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·931116 Method using Sample Doscrlptlon W-l0·C·Or)wall DW/JC Baths 2210005-1 t..ooJOA W·II·A·JoInl DW/JCoHice Compound counter 221001)541-0011 W-11-A·Dry.'1all OW/JC office 22 rOOO!i.f ''''oOlM counter W~11-B-Jdnl DW/JC office Compound counter n/OOO54I.(1032 W·II·B·Or;wall DW/JCoffice 221QOO5-II..I)OJ2A counter W -11-C-Joint DW/JCoffice Compound counter 2210005-11..1)031 Ana'JSt(s) Ell;) Ottlwn (G·I) DeCllvo/las Michael (20) Polarized Light Microscopy ~Qn·Asbes(os Appearance % Fibrous Bro.vnNJhito 10%, Cellulose Fibrous Heterogeneous White Non-Fibrous Homogeneous BrO\vnIVVhile 10% Cellulose Fibrous Heterogeneous White Non-Fibrous Homogeneous Bro ..... ruWhile 10% Cellulose Fibrous Heterogeneous White Non-Fibrous Homogeneous Asbestos % Non·Flbrous % Typo 90'% Non·fibrous (other) 100% Non-fibrous (other) 90% Ncn·fibrous (other) 100% Noo-f1brous (other) 90% Non-fibrous (olher) 100% Non-fibrous (olher) Erin Orthun. laboratory Manager Of other approved Signatory None Dotected None Detectod Nono Dotected None Detected None Detected None Dotected (}.;e 10 magfH~Ca~()(l Fmtta~()(1s !nheren! in Pll.!. asbestos fibe<s In d.men~51:~ow the r050:0\,00 capat);~tl'ul PU,1 may nul be de:ect&1. The 1:t1\,1 of de-~ection 3S slated in Ille method is 1%. Thot ato.\) lest U,po;! relates oory to the ilems tes!oo and may 001 te IEprOO1J(M ill any fcnn 'l.,thot.l tho e'press ~\ritlen app-roval of EMSl An31)tC"al. 10;. EMSt·s liab;~1y Is Lmited 10 the cost GI anal,s's. EI.lSl bears 1"10 (espoosibll~1 for samp:o collection ac~~ih1S cr anat,"tcal methc;j ljm;la~cns. hlefpfelation ar.d use of test resu:ts ar& the ro.spoosit;iMyofthe client Samples foce;"$:! In 9000 con~t:()(\ unless ol"er ... ·jso I\¢ted. ThiS repOl1 !(Iusl fI<Il bo USe-oj (0 claim product eMvs<:metll bl' rlVl.AP or an)' agency of the U.S. Go\'Ornmenl Samplos analyzej by EMS!. Anal.,fcat. tiC. 7J.3Q S. AHoll Way &Jikl·ng 12 Su:\o A, CentQl1Oia'CO Test Repql PLM· 7.12.0 Printed: 4112120106:45,12 PM 8 ( EMSL Analytical, Inc. • 7330 S. Alton Way Building 12 Suite A. Contennlal. CO 00112 F,1.lI: (303) NI-I400 Email: d<.!llv!!ll.li>u-mns\.r:olll . i Altn; Mike Semonisck Customer 10: HIGG78 Higgins & Associates, LLC CUstomer po: 8200 South Akron Street Received: 04l1?Jl0 2;00 PM Suite 117 EMSlOrder: 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phone: (303) 708·9840 EMSL Proj; Project: City of Wheat Ridge Analysis Date: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample Description W-11-C·OI)",aU DW/JCoffice 22JQ()Q541-OO3JA counter W·12·A-Joint DW/JC East Compound Garage 221000541-0034 W-12-A-Orywall OWJJC East 2l1~I.oo34A Garage W·12·B DW/JC Easl 221D00541.QQ35 Garage W·12·C DW/JC East 221000541-0036 Garage W-13-A-Jo1nt DW/JCWest Compound Garage 121{JO()5.J1.()()37 Analyst(s) Erin Orlhun (64) DeCavaflas Michael (20) Appearance BrownlWhite Fibrous Heterogeneous WhITe Non-Fibrous Homogeneous BrC:Nln.lWhi!e Fibrous Heterogeneous Beige Non-Fibrous Homogeneous Beige Non-Fibrous Homogeneous Non.Asbcsto§ % Fibrous 10% Cellufose 10% Cellulose No dr}wall present No dry ...... I! pms€1I1 Asbestos % Non-Fibrous % Type 90% Nco-fibrous (other) None Detected 100% Non·fibrous (other) None Detected 90% Non-fibrous (other) None Detected 97% Non-fibrous (other) 31>/0 Chrysotlle Slop Positive (Not Analyzed) 98% Non-fibrous (other) 2% Chrysotilo Erin Orthun, labOfalory Manager 0( other approved signatory Dee to magn;fic.alion lim,tatiCfls itlltetell\ in PlM, asbestos t:ters in d~'l1ens.'(fOs belO' .... tlte tesOlut:on capab;J<t/ of PUt mayMI be detected. The jimit of dele<lIco as stale<:l ill the method Is 1%. The abQ','I3le.s\ repqrl relales ooly 10 the items tes!oo and may not be reproduced;o any form v.ilhoolthe 'l'pre5.s \Hi!1en aPPfo',-al CifEMSl Anal)'tical, tr.::. EMSl's Ua~ii!y Is Ilmiled to the cost of analysis. EMSl bears 110 fesponsiblity for sam~e c,,1!~ctOtl actl\ities or 3Plalyllcal methw timita~Cf\5. nte-Ip!elatioo anoj use of tesl results are the resPQflSibilityoftha clien!. Sampfe-s rece;\'W ill gO<Xf cC('4'~CtllJnles.s o't.emiS9 l1ot'!4, This repott mlJ$1 not be lJsedloclalm ploolJCl endOfsemenl b'l tM.AP or arr/ agellcyol the U.S. Go\'\;mmeot Samples al1alyzed by EI.\S!. Anal}tca1. \1C-1)30 S. Alton 'IIa' BoJi!i1ing 12 Suite A Centenoia!CO Test Repcrl PlM-7.12.0 pfinted: 4/12120106:45:13 P,,"" 9 EMSL Analytical, Inc. 7330 S. Alton Way Building 12 Suile A, Centennial, CO 80112 fhone: (303\7,10·5700 FaK: (303) 741·1<\00 email: dorwer!ab·liu!l1sLcom Alln: Mike Sell10nisck Customer 10: HIGG78 Higgins & Associates, LLC Customer po: 8200 South Akron Street Received: 04/12110 2:00 PM Suite 117 EMSLOrder; 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phone: (303) 708·9846 EMSL Proj: Project City of Wheat Ridge Analysis Date: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method using Sample Description W·13·A·Orywall OW/JC West 22100054 '·OO37A Garage W-13-B-Jotnt OW/JCWest Compound Garage 22100054 1.0038 W -13-8-01)\\'811 oW/JeWesl 22/000S4I-OOJ8A Gamge W·I3-C·Jolnt OW/JCW",t Compound Garage 221{)(X)54/.£IOJ9 W-13·C·Orywall OW/JCWest 2l1Q005.fI.t)(J39A Garage W·14·A Wall Plaster 22100Q.S.f1-OO40 Analyst(s) Erin Onhun (64) OeCavaHas Michael (20) Polarized Light Microscopy tion·Asbe:stos Appearance % Fibrous BrmmlWhile 10% Cellulose Fibrous 5% Glass Heterogeneous Br{fflnJWhile 100/;, Cellulose Fibrous 5% Glass Heterogeneous BrownlWhile 10°/'1 Cellulose Fibrous 5% Glass Heterogeneous White Non·Fibrous Homogeneous Asbestos % Non·Flbrous % Type 85% Non-fibrous (other) None Detected Stop Positive (Not Analyzed) 85% Non·fibrous (other) None Detected Stop Poslllvo (Not Analyzed) 85% Non-fibrous (other) None Dotected 100% Non-fibrous (other) None Detected Erin Orthun. laboratory Manager Of other approved signalOl'I [Ne to magn:fic,;tion Iim'ta~GI1S <nMIef\t in PlM. aSbestos f,ters If1 d;menSiO<'lS be!G\v the re.scluti!)-l'l capao,f,ttof PlM may flot bl! iletected. The Um.! of iletect,on as stated ,n the melho1 is 1%. The a'oo·,"9 lest fepO<t relates only to the items tested and may not be feplfNuce<:! in any lorm ",ilhollt the ~HJ1feSS , ... ritteo apprO'lat 01 EMSlAnalytcal. h:. EMSl's lJabill~1 Is limited to 1M (ost (;1 ana!)~ls. EMSl bears flO IG-sp;:.r!sit'j;ty (0 sam~~e (orllK~·OIl a~ti~;,tTes or anatj1.·1;iI1 method ~m,lations. nterpretaliOO arw1 use or test results are the respwsibllity(;f the client Samptes fe<e;\'t'd In good CO!ld,tioo un~ess o:hel\~Jse note<:!. This fepGlt must flet be used 10 claim IlIOOOXt efl\1t'(semenl b'l NVlAP or ant agellcyof the U.S. Go·,'\lmmenl Samp!es anatyze.1 by EMSl Atla1,-tic-.al. ,"c. 7J30 S. Alton Way eu~<l;llg 12 Su;!;:! A. CenleMralCO Test Repcrt PUiH.12.0 Printed: 4/1212010 6;45:15 PM 10 EMSL Analytical, Inc. • 7330 S. Alton Way Building 12 Suite A. Centennial. CO 50112 rhOIIe! j30311-tO.5700 Fax; (303) Nt·Moo Em .• ll: dgrlVeri;lhfi'omsl.colll Ann: Mike Semonisck Customer 10: HIGG78 Higgins & Associates, LLC Customer po; 8200 South Akron Street Received: 041121102:00 PM Suite 117 H·ISlOrder: 221000541 Centennial, CO 80112 Fax: (303) 708-9848 Phone: (303) 708-9840 EMSL Proj: Prolect: City of Wheat Ridge Ana!~-sls Date: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample W-14-8 2210005-11-0041 W·14-C 22tOOO54I.QQU W-15-A 2210005~I.()(143 W-15-B 22100054I-OO.f4 W-15-C 221000~.f1-0045 W-16-A 22100054t.{IQ-f6 W-16-B 2211J01X»1-lX)47 Analysl(S) Description Wall Plas!€( Wall Piastef Brick/Mortar Brick/Mortar Brick/Mortar roofing roofing Erin Oltlwn (6<#) OeCavalJas Michael (20) Appearanco While Non-Fibrous Homogeneous While Non·fibrous Homogeneous GraylWhite Non-Fibrous Heterogeneous GraylWhile Non·Fibrous Heterogeneous WMe Non·Fibrous Heterogeneous Black. Fibrous Heterogeneous Black Fibrous Heterogeneous Non·Asbestos % Fibrous 25% Glass 40% Cellulose % Non-Fibrous 100% Nco-fibrous (other) 100% Non·fibrous (other) 100°/0;> Non-fibrous (other) 100% Non-fibrous (other) 100% Non-fibrous (other) 75% Non·fibrous (other) 60% Non·fibrous (other) Asbestos % Type None Detected None Dotected <1% ChrysoUle None Detected None Detected None Detected None Detected Erin Orthun. laboratory Manager or other approved signatory Oue 10 magl1if,call!)ll Jimi!Aticns iflherent ill Pll.!. asbestos f,bers in d;menSCflS be'ow the resciutioo capaMty of Pll.I rna,. not bo deteclN. 1M limit tj.f de:ectioo as. s.ta~ed in the method is 1%. The aOOI'6" 1651 feport retates only 10 lJ';e items tested and may Mt be reprodu(:ed In any form ooithoot the e>l)fess written ap~o\<ll or EMSl Ana:~al. 1m. E"~l's liability is limi!ed to the cosl of analiSts. EMSl bears no resporuit;Jity for sam~e col!ectiOtl acti\\(ies or anal;,tca! method Iimi!Afions. h!erpre1a~'(l(I and use oHest f(\SU:t$ alO the responsibility of the client Samples re<;;ilved In 9¢Od cOl'l(f,tiGn '.m!ess otler.vise noted. This report mlJstnot be used 10 claIm proou(1 efldOfsemelll b,. NVlAP or artl agency of!11e U.S. Go~'€mm&flt Samples analyzed by EMSl hlalyJcal, ~G_ 7330 S_ Al!O!l Way &ifd:ng 12 Su,le A, Centen"';alCO Tesl Repc<t PLM-7_12.0 Ponled: 4/1212010 6:45:16 PM 11 EMSL Analytical. Inc. • 7330 S. Alton Way Building 12 SullO A, Contennl<1l, CO 80112 Attn: Mike Semonlsck Customer /0; HIGG78 Higgins & Associates, LLC CustOlner po: 8200 South Akron Street Received: 041121102:00 PM Suite 117 EMSL Order: 221000541 Centennial, CO 80112 Fax: (303) 708·9848 Phone: (303) 708·9846 EMSlPrq: Project: City or Wheat Rldgo Analysis Dale: 411212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 600/R·93/116 Method using Polarized Light Microscopy Sample W·16·C 221000541 -<XHS W·17·A 22/0005$1-00-19 W-17·B n'~I.1}()5(j W-17·c W·18-A 221OOO541..vo52 W·18·B 221DOO5-If.co53 W-18·C 22tOOO54t.()()54 Analysl(S) Oescrlpllon roofing Brick Texture Brick Texture Brick Texture eMU Toxture eMU Texture eMU Texture Erin Ort/fUn (64) D8Caval/as Mich801 (20) Appearance Black Fibrous Heterogeneous While/Blue Non·Fibrous Heterogeneous White Non-Fibrous Homogeneous White/Blue Non-Fibrous Hete(ogeneous WhiteJBlue Non-Fibrous Heterogeneous While Non·Fibrous Honlogencous WhneJBfue Non·Fibrous Helerogeneous Non·Asbestos % Fibrous 30% Synthetic 15% Glass % Non-Fibrous 55% Non·fibrous (olher) 100% Noo·fibrous (other) 100% Non-fibrous (olhCf) 100% Non·fibrous (other) 100% Non·fibrous (other) 100% Non·fibrous (olhef) 100% Non·fibrous (olher) Asbestos % Typo None Detected None Detected None Detected NOlle Detected None Detected None Detected NOllo Detected Erin Orthun, labClalOf)' Manager 0( other approved signalOf)' Ova to maqn'~(~t:ol'l rmila~cns lMet1ln\.n Pll.I. asb€'ltos r.ters in o;l.rr.an!o Ofl.~ be'Q",'i li'a (e5011.l1:<)1'1 CJpab~~!y of Pll.I may 1'10\ be detected_ The lim.! of dE'teuien as sta!ed in tha melhod is 1%. Tho abo\'o lest repe<1 H,ta!es COlI' to 11'.0 ,\elliS lested and may r.ol bo (e,:ro1I.l(01 'II Jny ferm \~lthC\Jllhe a,pess ' .... ritten appfO'al of EMSl Ant.i)t(al, rn.;. EMSl's fiabitity Is limited 10 lIlo cost of 3113f}SiS, EI.ISl tea's no rG-Sp.ons;bhty ro.r samr1a co'le<tio:'\ Jc~\'t'es Of a!'lal)vea! meth04 r;miU~()-f1$. 11Ierpre'a~1).f\ and USO of t~SI (fsSylts alo tha (osponslbi!.ty of the (l'anl, Samplos re(eil'llcl fn good ~0tl~t"1)(I tlme-ss o;l;er,o,'ise noted. This repGfl mtl~1 not ba used to cla:m product endorsement hI' tMAP or any agency of tho / U,S. Go\ommenl Samples ana!YJ-OO by EMSl Ana! 1leal, Ylc. 1330 S. AJletI Way Boi!'_fng 12 Suile A. Centeno,aleO Tesl Report PLM-7.12.0 Prinla<!: ·111212010 6:45:17 PM 12 ( EMSL Analytical, Inc. • 7330 s. Altol) Way Building 12 SUito A. Centennial. CO 80112 Altn: Fax: ProJect: rhO/lo: (If)J) 1·10·5700 I, Mike Semonlsck Higgins & Associates. LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 708·9848 Phone: City of Wheal Rldgo Customer 10; HIGG78 Custaner po: Received; 04/121102,00 PM EMSlOrder; 221000541 (303) 708·9846 EMSL Proj: AnalysIs Dale: 4/1212010 Test Report: Asbestos Analysis of Bulk Materials via EPA 6001R·931116 Method using Sample Description W·19·A Roof draIn wrap 2210005-f I .0055 W·19·B Roof drain wrap 221000-541-0056 W·19·C Roof drain wrap 221()()!)..>ft-0057 W-2Q.A Seam swan! black UII)X<$-.fI.J)l)58 W-2Q.B Seam seaan! black 211000stl-0059 W·2Q.C Seam seaanl bJ<N;k 2210005-U-CIOW W·2t·A Hoof brick taulk 221000541-0061 white Analysl(s) Erin O,IIJUn (64) DeCaval!.1s MJchaol (20) Polarized Light Microscopy ~on·Asbeslos Appearanco % Fibrous White/SlaCK 70% Cellulose Fibrous 10% Glass Heterogeneous White/BlaCK 70% Cellulose Fibrous 10% Glass Heterogeneous White/Black 70% Cellulose Fibrous 10% Glass Heterogeneous Black 5% Cellulose Fibrous Homogeneous Black 5% CeUutose Fibrous Homogenecos Black 6% Cellulose Fibrous Homogeneous GrayiWhite 5% Synthetic Non-Fibrous Heterogeneous Asbestos % Non·Flbrous % Typo 20% Non·fibrous (other) None Detected 20% Non-fibrous (other) None Detected 20% Non·fibrous (othet) None Detected 95% Non-fibrous (other) <1% Chrysotilo 95% Non-fibrous (other) <1% Chrysotllo 95%t Non-fibrous (other) <1% Chrysotile 95% Non-fibrous (othef) Nono Dotected Erin Orthun, laoomtory Manager Q( olhef approved signatory Due 10 ma9'1,f,caMnlim;!atcns 'nhe(1)01 ,n PtM. asbestos (,hefS in lfmM$uns b~lQW 1M lesc.11J~Qn. capab~:t:t' 01 PlM may ncl be d!:te<:ted. The I"m,1 QI dete(!icn as staled in the melhoo Is t%. lhe abo,>'6 tM\leport lorates only to the items te$tw and may Mt be reptO<!ti(oo!n My fOo'm \\iU101Jt the e'piess 'Milten a~~o...al of EMSL AIl¥)'llcal. t-r.. EMSl's llab-illl)'is \;mi:OO to U10 COil of analysis. EI,ISt bears no respcn.sl!:otitl fUf samfle cO:'ectioo acti\\ties 00' ana!y'.ica! metho1 !,mitatioos. ~telpretatioo aod uss of ted '~l.Ilts .lIS til" respoosiMty of tho clteot. Samptes recehw 10 good coM.6cn un!ess otler,o,ise noted. lhi$ (epoit must no!. be used 10 claim PIOOIY.I efldcrsemenl by tMAP 01 Jny agency or the U.S. Go\"Gmmell! Samp!es analyzed by EMSl Arr,l;I(~ca', nco 73YJ S. Allon Way Bu;~;f19 12 Sl.tite A. Cen!er.n1aiCO Te,l Repa1 PLM·7.12.0 Prinled, 411212010 6,45,18 PM 13 ( EMSL. Analytical, Inc. • 7330 S. Alton Way Bllildlng 12 SllltO A. Centennial. CO 80112 Alto: Fax: Projecl: Phnnr.: l3Q3) 1.tO-5700 I, Mike Semonlsck Higgins & Associates, LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 708·08<18 Phone: City of Whont Rldgo Customer 10: HIGG78 Customer po: Rcceived: 04112110 2:00 PM EMSL Order: 221000541 (303) 708·08<16 EMSL Prcj: AnalysiS Date: 4/1212010 Tes! Report: Asbestos Analysis of Bulk Materials via EPA 600/R-93/116 Method lIslng Polarized Light Microscopy Samplo Description W·21·B Roof brick catllk. 2110005-fH/OQ2 while W·21-C Roof brick caulk 2210005-11-1..')063 white Analyst(s) Erin O,1Iwn (64) DeCavalk1s Micll{l81 (20) Appearanco WMe Non-Fibrous Homogeneous G,ay Non-Fibrous Homogeneous Non-Asbestos % Fibrous 5% Synthetic 5% SynlheUc % Non·Fibrous Asbestos % Typo 95% Non-fibrous (othCf) 95% Non-fibrous (other) Erin Orthun, labocatory Manager or other approved slgnalory None Dotected None Detected Due 10 magn,f,catior\ I~T"tat(ll\S mhelenl in PtM, astestcs CtINS in d"roens'C{lS be:o"N Il'Ie 16S0'utiGf'l capab,',t/of PUt ma'l nc! be deteded. Thu lim,! of d<1'!/XtiC<'\ as slated in the melhod Is 1%. The <100\1) test rEilM relates 0111'110 the items testoo and ma'l not be repro1lXed;n any (OM .... it/lCclthl! 61pre5S written ap~o'.-al 01 EMSL An31yical, Irr.. EMSl's Jiabitity is t:mited 10 lhl! tost of an~lrsts. EMSL bears no (6Sponslt.lotf fOf sample cofl~b'oo a,~\it:e5« anal;tit4l metl'loo limlt3~OIlS. hte[prela~oo and lise 01 test (:$11'15 aro the tespollSibNi' of the client Samples flxei\'01 in qood COl1ct<I!O'lun!eM ott'lolWiso noted. This repCAt mustoo\ bo usello claim pro1!iC1 eM(){Sement b'l tMAP Of .lny allMC:l0flhe U.S. G:r.-ell1menl Samptes afla!yz&>i by EI,lSL /vlal)tic.aJ, ~c. 1331) S. Meo Wa,! &l:Id:n<j 12 Suim A Cenlenn:a~CO Tesl Repcrt PlM-7.12.0 Prinled: 4/1?J2010 6:45: 19 PM THIS IS THE LAST PAGE OF THE REPORT. 14 ( EMSL Analytical, Inc. 7330 S. Alton Way Building 12 Suito A. Centonnial, CO 80112 Attn: Fax: Project: Phon.:-: (303) J.10.5701) " Mike Semonlsck Higgins & Associates, LLC 8200 South Akron Street Suite 117 Centennial, CO 80112 (303) 70a.9848 Phone: City of Wheat Ridge Customer ID: HtGG78 Customer po: Received: 041121102:00 PM EMSlOrde!: 221000541 (303) 708·9846 EMSL PrO!: Ana!ysls Dale: 411312010 Test Report: Asbestos Analysis of Bulk Material via EPA 600/R-93/116. Quantitation using 400 Point Count Procedure. Sample W·1S.A 22tOOO5-lt-tJO--l3 Analys\(s) Erin Orthlln (1) OescrlpUon Appearance Brick/Mortar % Fibrous Non·Asbestos % Non·Flbrous Asbestos % Type 100.00% Noo-fjbrous (other) <0.25% Chrysoille Erin Orlhun. laboratCty Manager Of other approved sIgnatory Oiscla'm"r.$oma samples maj'ton!.;,n as-lieS-It» fibers presenl ill omC<'\$4:lns be!O' .... PlM 1i!$oIu\i"Otl limilS, The hmil M detection ,'15 stated On the methOO is O.25~' .. EMSL AnalytJ(:al ~~ 5t.:9ge5ls thaI samples reported as <0 25~·.<Jr Ilona delecler.l undergo addic-onal anat)'Sis \is TEM. The at!{I'.'$ tes\hlpo.1 relalM (lilly to the il€ffis las-tw. This report mal" not be reptoducM, euept in foil, w,lhool .... riUell applo\-al of Et.lSl Anal)tle,lll1c. This [HI fep«t mllS! not be used by the o'en\ [0 <:Ia·tr\ p(OIivet eni1G1sementby HVlAP Of ally agen<:y of !he U{\ite<:! Slates Gm~mmenl EMSl Anal)1Oe.aI1nc., bears norespon5ib:lit, fOf sample co'lection 8c~\i[as, anat)tical me\l".ed limilal;Q(lS, Of !he acctlf.acyof resuits .... f1erl req\!&Sled to s&palate 13)"EHed samp.:&S. EMSl Analyllc.:!! he., tia!li!;ty is lim;l<n to the eCil (jf sample 3nal)'Sis.The test results eOflt.a:ned \~;lhin thls feput meelthe requiremenl:s of NELAC utile-55 OIherwise tlOled. Samples leceil'6d in go.od eoo4i(oo unleSS o(her,.,.;Se noted. Samp!es anatyz&d by E1.ISL Anat~tcat, he. 1330 S-Nloo Wa., Build;ng 12 Suite A CEI,teonialCO Test Report PLMPTC-7.12.0 Prtnted:411312010 11:14:53 AM THIS IS THE LAST PAGE OF THE REPORT. ( Asbestos Chain of CListody 2:.! .. :::;~ I ... ,'.;:. ..; -,~. L';. -::',1(,: 1\ "J. I;'. .. ~'?'!lE~!~}, .ti~Ogi~!'J~_ Ass(Jdah~~. LlC ~ ~ --.-----_. Street: 0200 Soulh Akron Street __ !?~I_I.t~.!·IL" ~_ -----.. ---- City.; _~~~!t~_/l(~inl i S:!atr~P{('I'Ijf1C:c' (~0 __ . ---.... -- Roport To IN;1rllc): Mike SCnlonisck ---'-.-.'.,--.-.. _--.--~-,--.---..... --. ,,--'- E ,I L::-'. " ."'_ ,':";i>i ,, __ :~: ;;1" L ~'f ::JJ~. :k .. \· ~'4(' S7(Jfl 3~: '.' -;..! -; I·Hl( EMSL·8iil to: @'Sarne LJ Diliownl I! El,L!,; l~. ()It.~h'''~: I~OH! "1~llt :r'GI):. ,r· CCn\n\~(\\;" fl1irC P.?!.£IJ!lflir)r!.!.p..F'JI'c:; \~I!..t:!':J!.!!.[~I!!.!~~!2,,'!.!_~/tir(/ mlltl' ____ ?jP-~~,~.~!~_C_odo-: Sill (~ ! qpunl!I'~ __ ._---.--.-.. - Fax II: 303·70&·9il·13 .-------_.-." -----" ---.. -.. '-' ~ __ .. X::'f!!al! ~clcJre.:;s. . r.!.~~E!l~.o~i.!.'_~t@J.!!tHJ!ll~~~~'1!F~so::a~~s ,co~._~_ _I~~5~{~J~;_}9~.70~:?!3'1?_Q~!I. ~~_~.9~~~.~dA ... __ . Pro~c: Namc!Number: C·,\)."i.. t.:J.~"'-~_1!.· A11:~~'~-.-.. '"'.' -------.------P.!.~sl)·PtovTde ~e-Sl;I~~:_J:~i.a.:: __ G::E"r!la!l i tl!rct~(>~.~!..~~[-,,--,---==-:.-'.,-,,-_. ,v,fl. ~ti1te Silr_I.~.uIH~ Takc;n: S~ t.J ~,},; )~Jcr6Ho,-~--T\lrnaro\lIl(U!~l1C (TATLOpt,on,' -Plea •• ChecL_ .. _. ~.-"...-r -6 HOUIS -TO 24 firs I 048 It.. I 0 3 DilyS I 0 I. Days LO 5 D"~5 I n 10 Days 'foc IEII "" 3'''''''~~~ ploa'" «w .,"',,"" .".N"",· . TI,er."s ,,,,.,,,,,,,,, eilO'", 10' J YOU' la.I "'"EilA c.-iii''; ""01/1 fAT Yo" ,,,I t< .,,>o,lIe "0" ." ,,,1/,,",,,,,,,., io"" led"" ''"'',,~c A"n;"', oM'Melo/l '" .",,,a,,,,,·,· ",'0 EMS', ,.-to" .",,' C","'lim.' 10e"""I,,, """n""",1 p"" G"',,, PCM. Air \ ",., 0 TEM • Air i T~M-Dllst o NIOSH 7400 '-'"":', ~ )., -;~~:\, u 0 I\HEKA ·:0 CFR, Part 'lC\ I 0 Micmvac . /l,STt~l D 5755 o w: OS.HA Bhl. TWA ~.". ,\~O' 0 NIOSH 7402 0 Wipe· ASTM 061,BO PLM • Bulk {reooding limit} 0 EPA Lovelll JJ~DrPOI Sonication (EP.4 000IJ·93/157) o{pLf>.·1 EPA 600/R·93!~ 16 (< 10/,,) 0 ISO 10312 Soil/RockNermlcullte ----------o P!HM EPA NOB «1'%) TEM· Bulk o ?LM CARS ,35· A (0.25% senslh',ily) Point Count o TEM EPA NOB o PLM CARS '135·6 (0.1% sensitivity) 0400 (00;0.25%) 0 1000 (~O.1%) o NYS NOB 19B.': (non·!nabl<.·N\'j o TE}"! GARB 1135·8 (0.1% sensitivity) POinl Count w/GravimcUic o Chatfietd SOP o TEM CARS 1,35· C (0,01% sonsllivily) 0·100«0.25%)01000«0.1%) JJ -rEM Moss Analysis·E?/·. (lO(l sec. 2.5 o EPA Proto8nl (Semi·::Juantltative) 0 NYS 19B.l (friable in NY) TEM -Wator: EPA 100.2 Lg cP~·~otc-:~!jOua~.!.~ta"ve} 0 NYS 198,6 NOb (non·frj.;Jble-NY} Fii.lors >10lJm o Wast" o Drinking Other: 0 NIOS"': 90021,.:1%) AI! Fiber Sizes o Waste o Drinking 0 gCheck For Positive Stop Clearly Identify Homogonous Group S"mplers Name: /"\ i "" 5~ .~.,.",-'. J(.I< I Samplers Signature: (l /', ~. .1/ • • <. ........... ~ .... I..,~ Smllple t: Volume/Area (Air) DatefTlme Sample Description HA # (Bulkl Samoled L0 ~ I -.L\ \ ).-" I) \'''''I~'i. ... '(\'''' \ ~4' f/L'A 'i-/! Iv -{\ ,. . ->: .. I - Lv -'2 . (.\ 17.11) \ ;~"'it'"'v,), -I'}~' ~ i) , .-<-,. --~-------- ~" . 2 -PI 56({; 1'-/"1,.'1(\1/\'1 ., \I(//V"·/ ()(' hi,I.' -, , -----" -[2, ,. ---_ .. , ._--,", ----------" , --"--... ---_. S~.n! S~~.r)ln_E. {~r.~._~t .. ~ ,-I ._-. w ) I-e Total 11 of Sampl.!!.~~~~_~. ._-._-, -_._--. --------_.- Relinquished (Client): 1Ir--. SLv"",,''-\la..;( Dtlte: Lt· 1.1. • Je) Time: ReceIved lLabi: d:=:t",d > t ') 'l\~\ ,i Datdf12\l= -'-. I il \, Time c-) 1/1'11 Cornmen!sfSpecl;:t1 Instructions: < I .-- P'--<"l( o ~,--,<'. .-o ... [h 'j,,, JjJo (I 'i'{' .:< L. y \( ~'""'."'''':~'''''"''' -'H .. ~<l vw~·;I' • :'1',.',':' ( Asbestos Chain of Custody EMSL Order Number (Lal> (l,w 0",,1 -------, ---.. ----~-----------... - ------"-_____ ~ __ ~J 0_ 0 0 5 4J___ AdJiflOl1<1I Pc1fJlJ~; of the Chain of Gust,xly (Jri..,' olif>, f/ecessary if needed lor iJ,fditfDfJJi :,aI110ic miormation Volume/Area (Air) Dale/Time S:Hn~lc # S'1111H.~~R..IJ:>.~iptiori ________ ,, __ ---flA # (Bulk) Sampled w-I---f-\ I~ -3 L .51--.,u I I:,. '" It ",1.-1 y.d~P-&t\.L...... __ NJ11_-'t-Ilf<) ------\cl-q-11 V r \ -1,-J--'+-f?; IiJ~.l.1~' I-~_ -- -B -- ------- -[ I I ------- ~'-l . s-1'\ -I I~, ">t';\J lji{;Z/ \'2, " ---- .-C " I~ -l A ( ,V1V T t' 1j,1L.t'..-( (, I tl L __ . - -~ I, -l ,I I\) -1 A C(Y)V 1 f" fIJ, L-(t'I(.-J ~ .~ \ , -(. I \ v\j-'~' 0 (LIVI f::y,v ( whJe) -~ , \ _. -----0: -c " V 'CommOflts/Speciallnstructions: Page ~ of --S.-pages ( Asbestos Chain of Custody , ___ ~MSI202t!d'lO'1~5(4ill~~ O/!~I ___ _ '. , . ' AdciitlO/"h1i Pa~1es oi th[> Cham of ellstcd), (Ire only l1i:C()$Saf.'l if nl'!t1afHi for ;lcidwOfWI samplt: illiarmation Volume/Area (Air) DiHcfTinw ._ ~"_~~!llpljJ JI. _'" Samele Des~!J,!?tion 1'-"-!IlB-"IX~ SamphHl _~v '':L I} c ~eb1.L':£~ibl-J IV III 'I'p.· 10 ---, - 'is -------- \ \ -r... \ \ ---_ .. ~'0' I c, ·A Di/-l he !?(\ +t, S .f; \ \ -c I \ ---.. I~,q-(i Dv-v )je ()ff: (C (<'L,.,j,· I- f) 1\ ------- \ I C ~\J i)-A \)w l J( £ t,-<:]t G~l\r,"~(o-r:. of; , . ( I \ v,""~ f') ()~~ he:: v\l.:' :;+ 0-({ "'i.Nl - '8 '/ I' l II I\J ' Ill_ A -_ .. 'u l;\i(>.\\ vic,) I-t( v 'Comments/Spcciallnstructions: ~ S Puge ~ of __ pages ( Asbestos Chain of Custody _ _ __ ~",1 ~ !,0r. (~E!!_l"llin bcr{ L iI b u'''.9c",-' ____ _ _ __ 2&Lo_QQ ~_1L=-__ -.. : '-. -- Additional Pd~;e$ of the elwin 01 Ctlst,)(Jy Dt2 only fwcessmy if nea(!eo (or [l(/(iItlOfW/ sample information Volume/Aroa (Air) __ S'HHe'o # --Sample Description --~.--~- _ . ___ HA !:J8111kl LV-!l/.P, -J) 1,01\ \ \ Flc\SI/ : iv /1) -. C \ \ --------~ ---.. -----~->---------- V\j'\']1\ b{,(k I flit" (-'V - ·G j' -- L j, L'0 . \G \\ «'(./.':9 -\~ , I . -C I I I\) • 17 1\ 13, ,(Ie --/ . It/' 'II.'C -E2 I I ( , \ '- I\! \'D' \~ { /viU Ii' )'f\I/<" -~, \ I -( , I I,\) . vLJI 1«\· { I J. . {"VII" f! (,Ci II! . p, ' ( ,V 'Comments/Spac!allnstructions: Page -1_ of S pages Oa(clTimc Sampled - 't-!I-/L) --~--- . Hl000S-IJ __ , -_ .. --' r· Addillollc1{ P{lUes of tile Cham of Cllstolly nrc only flocessnry if needeli fOf n(/r!ifiorwl stJlllpie iniormation S;"Jrnplo fI Sample Description . --,-_. --------r-'--,-------------'-----"------- I,,; '1(/ -c (2, / / ' (,,"·t (:-/d1n {.....;/dl~ __ .-____ t S:'~!Jvl S-"q/" 11:.1 -:Jjlt'l (/-l;v-~o' 0_ /2.,"" r-" If 14 Oit/k-1d-t r .. -(2, , I 2- [ I ( . I;"'¢l-i'~ {(t'<' ( ['/11 (.J (?i/.// tvA/if. .. (7, ,1 -c ' I l;h\ 'Cornrnents/SpeciLlllnstruc!ions: Pa~Jf~ ~ or ("') pages / VolulllcfAfea (Air) IIA /I (Bulk) /VL~7 , ---- Date/Time Sampled __ I J' II .. /<> .. - ~ ( Limited Ashestos SUlVt,W 7300 W. 411111 Ave .. Wheal Ridge, Colorado Appendix C Inspector Cel'tineation ( STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Department of Public HClilth ,/ and Environment AirPo!\ptI~ilCPl1h;otJ)ivi~ion T!lis certifies thai Robert')Mfchael Semonisck , ( Certification No: 10554 has mct the req\lirementso(25.+507, C.R.S. and Ail' Quality Contrpl Commission ReglOgtion No. 8, Part B, and is hereby cei~tified by the state of (.-:OIOl';1do in the followingdiscipline: Inspector/Managem~llt Plapner*.· :' \~ . ' Issu ed: 2/8/2010 Expires on: 2/812011 ... This cerlijit-ate Is mild 0111)' wltlt t/Je possessioll of(1 clirrelli DMs/oIHlpprO)'t!l/lrallllllg cours/! certification ;/1 fhe disclp/illl.' specljit'tI (fho~'e. ( STATE OF COLORADO ASBESTOS CERTIFICATION* Colorado Dcpartmcnt of Public Health and Environment Ail' Pollution Control Division This certifies that Michael K. Hartman Ccrtil1clltioll No: 16097 has met the requirements of25-7-507, C.R.S. and Ail' Quality Control Commission Regulation No.8, Part B, and is hereby certified by the state of Colorado in the following discipline: Building Inspector~~ Issued: 112112010 Expires ou: 1/21/2011 ,r. This certificate Is Wllid ouly witll,lte possessloll of (I curr,'111 DMs/oll-approl',·" Imillillg COIf'S/! t't'rlljlcatloll '" lite dlsciplille specijied "hOI't', Limited Asbe:.aos Survcv 7300 W. 411111 Ave .. Wheat Ridge, Colorado Appendix D ]}rnwings lliggills alld ,·\ssocia/l's, 1/1 F, ~ ~ ~ .. FD [conKey ACM: Linoleum Flooring (under floor tile) Drywall Joint Compound Black Floor Mastic Fire Door (Assumed) 1---------------------:. ______ ~q\,\,!?99JL ____ _ CINDER BLOCK -------, City of Wheat Ridge W.44'" AVE ·~~~~~~~~~~L;§§9~~~~~~~~~~~~~==~==~===~~~~~?~~=== __ BRICK HIGGINS AND ASSOCIATES, L.L.C. ".""",N!>; 1(),o1oM.<~"""", .. '...t O..t.>c.....~d ~"''''''NO WR..Q410 4-13-10 4-12_10 041210-1 AYlno"",, l~i.4G.oIlu<> JMN 0_ RMS 0.",,, ... 1: '""' Appendix D ACM Location Drawing April 2010 ,-" 1 City ofWhea{ Ridge I QtyotW"""'~ JMN I ioN<> rmw.·'"" .... 0' i .....-'tI<lGol. co ~OO:l:l s..rnpIot.o<:a/lon .... ~APRIIlI>p\ OFFICE FD _______ 1 Appendix I Jefferson County Inspection Report -':-,,----'=r7'-"~~~~~~.'-.'-~' ,'""",",,'--C"''''7',.-;-;---;--..,---'"',.,....,.--.,--,-~~-,~·-'~~-·~r~_~..,....'".,..~ ".-'--~-~~----~.~, '~-.. -~-,~,.,._;-~,-'-~,~'-,-c_7 __ .-, _,-,_---,-__ ----...-,.'_~ ____ , ,.,. __ _ -~., . .. Co.lorado Department of Public Health and Environment I: ~\~J . REGULATION NO.8. PART B ·./87.rY"fl&lyA 45 tV.. NOTICE OF INSPECTION Colorado Dept. 01 Public HeaHh and Environment APCe-s8-S1 4300 Cheny Creek Drive S. Denver. CO 80246-1530 Phone: 303-892-3100 Fax: 303-782·0278 Date Time In/Out Inspector(s) Facility Name/Add/ess /CuJ/ DAv I b Itt VI" I Building Owner(s) Contractor Permit # Person(s) Interviewed J I Entry by Consent: I!;( / Warrant: 0 Reason for inspection: ~Routine Compliance 0 Complaint 0 Other (specify): ------------------------------~----------------------------------------~ REQUIRED ACTIONS: Iv --..----1 , ~r~ ri' i,' .-------.-----------------------------------.--.---fV"--. G---. / I"; .-------.----.-------.. -.--.---.------.-----------------.------L:. f--L.-i~...;lT.-.- ,/ -/./V!) Were all problems resolved at the time of inspection? YO NO NlA 13; CDPHE follow-up needed? YON IU-~ Samples (splits) taken? YO Nt.t· . Pictures taken? YO NO" ' Sample #s thru Documents collected? YO Nc:i'" THE DIVISION WILL REVIEW THE INFORMATION COLLECTED DURING THIS INSPECTION AND A DECISION WILL BE MADE REGARDING COMPLIANCE WITH ASBESTOS REGULATIONS. THIS REVIEW MAY SUGGEST ADDmONAL ITEMS REQUIRING FOLLOW UP. t1J CONTRACTOR o CONSULTANT o OWNER [J OTHER Print Name prime....,.." ...... PrlntN .... Copy to: Wtite -CDPHE. V.IIow-Contr.ctot, Pink. FilII Acknowledgement of Inspection i) (JYJo 11'( ;9/') SignN .... ShHI_",_ R.v.: 11106, J;\\lb"tol.m lllid ~I FOt1I'II\cOPHE\NOI.doe Appendix J Permits Submit form to: Permit Coordinator Colorado Dept. of Public Health and Environment APCD·IE·B1 4300 Cherry Creek Drive South Denver, CO 80246·1530 Phone: 303..a92-3100 Colorado Department of Public Health and Environment ASBESTOS/DEMOLITION NOTIFICATION and PERMIT MODIFICATION FORM Fax: 303-782-0278 asbeslos@slale.co.us Name of Facility: I Facility Location: Antique Mall 7340 West 44"' Ave, Wheat Ridge GACIConsultant: I Phone # I Fax # Alpine/S&R Environmental 303) 421-3366 (303) 940-0868 E-mail Address: I Permit Number (if already issued): dale@aIQinedemolition.com IIJE0783A Please check the appropriate box(cs) in A, Band C, as applicable: A. Upgrade to: 0 30-day permit o 90-day permit o I-year permit B. 0 Request to cancel above notice/permit. (All but $80 of the application fee will be returned. If you paid by check or money order, a state of Colorado Warrant will be mailed to the company appearing in the contractor box on the application. If you paid by credit card, a credit will be issued to the same account used to pay for the original application fee.) C. Change in: o Supervisor: ____________________ .Certification # _______ _ DA.M.S.: _____________ _ Certification # _______ _ o Project Manager: __________________ .Certification # _______ _ o Start Date: ____________ _ o End Date:. _________ _ o Work Times: ______ D Disposal Site: _________ 0 County: _______ _ ~dditional Scope of work (include type of ACM, quantity, location in or on facility and work practices): The Address for the project is 7340 and 7350 W. 44"' Ave .. Wheat Ridge, not 7300 W. 44"' Ave. The building is actual two buildings built together with two separate addresses. I certify that I am the person authorized to sign this modification on behalf ofthe General Abatement Contractor and that all statements made in this modification are, to the best of my knowledge, correct and complete. (Note: Making false statements on this application constitutes second-degree perjmy as defined by 18-8-503 C.R.S., and is punishable by law.) 4/412011 Date Dale Gibbs Manager Printed Name Position or Title TillS Box IS FOR CDPHE USE ONLY: Postmark or Hand Delivery Date: Approved By: I Code: Form o[Payment & #: Permit #: I Record #: I Date Issued: Fonn:NPMO& Rev.OIIJOIOR Colorado Department of Public Health and Environment Air Pollution Control Division -Indoor Environment Program -Asbestos/lAQ Air Unit 4300 Cherry Creek Drive South, APCD-IE-B1 Denver, Colorado 80246-1530 Phone: 303-692-3100 -Fax:' 303-782-0278 E-mail: asbestos@state.co.us DElVIOLITION APPROVAL NOTICE This approval notice is granted subject to Colorado Air Quality Control Commission Regulation No.8, Pmi B, adopted December 21, 2007, and effective January 30, 2008 and the Colorado Air Pollution Prevention and Control Act C.R.S. (25-7-101 and 25-7-501 et seq). This notice signifies that the structure was inspected for asbestos, luminous exit signs (containing radioactive material), and Ozone-Depleting Refrigerants and the demolition contractor has properly notified the Colorado Depmiment of Public Health and Environment pursuant to Regulation No.8, Pmi B. As a contractor, you may be subject to other demolition licenses and permits, depending on the requirements of the county and municipality in which the work is being performed. The Colorado Depaliment of Public Health and Environment, Air Pollution Control Division, strongly suggests that you check with county and municipal authorities in order to determine any other local building/permitting requirements that must be met. Please note that certain asbestos-containing materials (ACM) may remain in the structure during demolition. Therefore, any demolition debris left behind after the completion of post- demolition site cleanup may constitute a "reason to know of asbestos-contaminated soil" at the site, subject to the requirements of Section 5.5 of the Solid Waste Regulations (6 CCR 1007-2, Part 1). THE ORIGINAL APPROVAL NOTICE MUST BE POSTED ON SITE AT ALL TIMES. Immediately Ilotifj> tlte AsbestoslIAQ Unit of project modifications byfax (number above) or e-mail (address above) alld the appropriate county health department by fax. Project modifications include changes ill the scope of JVork or the scheduled JVork dates, etc. This demolition approval notice is valid beginning 4/1/2011. The actual scheduled work dates are from 4/112011 through 4115/2011. Approval issued on: 3/2112011 Record number: 77140 Fee Paid: $55.00 Notice Number: llJE0969D For the location specified below: FOI'mer Gas Station 7300 W. 44th Ave. Wheat Ridge Jefferson County This notice has been issued to: Alpine Demolition 5790 W 56th Ave, Ste. C Arvada, CO 80002 Check number: 1472 Asbestos Building Inspector: Greg St. Louis Cerification No.: 11407 Inspection Date: 03/1712011 :Olorado Department of Public Healdl and Environment General DEMOLITION NOTIFICATION APPLICATION FORM APPLICATION FEE MUST ACCOMPANY THIS FORM INCOMPLETE APPLICATIONS WILL BE ---._-----:---. (Notice will be mailed to the demolition contractor unless ~PJ"cilfie·( {,otherwise) Fee: $50 + $5 per 1000 ft' of area to be 55,00/ (See instruction #1 on reverse side) /. ~ (J) C o :e '0 E Submit form to; Permit Coordinator Colorado Dept. of Public Health and Environment . __ APCD·IE-B' 4300CIlE)rry Creek Drive South \ Denver, CO 80248-1530 Phone: 303-692-3100 Fax: 303-782-0278 Asbestos@state.co.us ClI c Ji-wrecking 0 Burning t 0 Implosion 0 Moving 0 other, specify: additional authorization -Please call (303) 692-3100 and ask , Contractor (GAC) CDPHE Asbestos Permit # Removed possess i state i as ... an Asbestos Building Inspector. I also certify that I have thoroughly inspected the facility to be demolished, as listed il in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of ~ asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the ~ c facility.' I also certify that I have informed the owner/operator of the facility or the demolition contractor that any :g ,g asbestos-containing material allowed to stay in the facility must remain non-friable during demolition. Specify type(s) 1;; rl of ACM remaining, below: (check appropriate box(es)): Q)l+= ~ ~ Vinyl asbestos floor tile 'C u tar ., ~ ~ 1:: ., u I I means i! , Category I nonfriable ACM that will be or has been subjecled to sanding, grinding. mtlllng, or abrading or (dl Category II nonfriable ACM that has a probability of becoming or has become crumbled, pulverized, or reduced to powder by the forces expected to act on the material in the course"of-' demolition or renovation operations regulated by this regulation. Note: Asbestos-containing sheet vinyl and linoleum must be properly '. abated/removed prior to demOlition. -; E~ Fonn: DNAQ8 Rev. 01~ l, ~ '5" Colorado Department of Pulll!c HeC\lth and Environment Air Pollution Control Division -Indoor Environment Program -AsbestosliAQ Unit 4300 Cherry Creek Drive South, APCD:IE-B1 Denver, Colorado 80246-1530 Phone: 303-692-3100 -Fax: 303~782-0278 E-mail: asbestos@state.co.us , ,. ASBESTOS ABATEMENT PERMIT This permit is granted subject to Colorado Air Quality Control Commission Regulation No.8, Part B, adopted December 21,2007, and etrec'tive January 30, 2008, the Colorado Air Pollution Prevention and Control Act (25-7-101 or 25-7-501 et seq., C.R.S.) and the following provisions. It is onlyJQr the purpose of allowing asbestos abatement. ADDITIONAL PERMIT PROVISIONS: By performing work under this permit the abatement contractor agrees that the Division may revoke or suspend this permit should the 'Division find that the contractor: ~ has violated or has aided and abetted in the violation of25-7-1 01 or 25-7-50 I et seq., C.R.S. or Regulation No.8, Paifif or an order of the Division or:Commission~ • has failed to meet any permit and notification requirement or failed to correct any violations cited by the Division during any inspection within a reasonable period of time, as may be determined by the Division, • has used"misrepresentation or fraud in obtaining this permit, or, • has committed any act or omission which does not meet generally accepted standards of the practice of asbestos abatement. As a contractor, you may be subject to other licenses and pelmits, depending on the requirements ofthe county and municipality in which the work is being performed. The Colorado Department of Public Health and Environment, Air Pollution Control Division strongly suggests that you check with county and municipal authorities in order to detennine any other local building/pelmitting ,requirements that must be met. THE ORIGINAL PERMIT MUST BE POSTED ON SITE AT ALL TIMES. Immediately notifY the AsbestosilAQ Unit of project modifications by fax (nllmber above) or e-mail (address above) and tlte appropriate county health department by ffL¥. Project modifications incilide changes ill tlte scope of work or tlze ' scheduled work dates, etc. This asbestos abatement permit is valid beginning 3/15/2011 through 11 :59 PM on 4/13/2011. The actual scheduled work dates are from 3/15/2011 thmugh 4/15/2011. Approval issued on: 317/2011 Record number: 76887 Notice Number: llJE0783A Variance: Comments: None None For the location specified below: Autique Mall Ground Level and East Eud of Bnilding 7300 W. 44th Wheat Ridge Jefferson Connty This permit has been issued to: Alpine Demolition & Recy~ling, Inc. 5790 W. 56tll Ave. #C Arvada, CO 80002 Fee paid: $400,00 Check number: 1448 Project Supervisor: Matthew Snyder Cerificatioll No,: 17427 Project AMS: Alexander D. Green Cerification No.: 15745 Project Manager: Issued by: LBM . ':=-Z&4~1 City of Wheat Ridge Commercial Demolitio PERMIT -110329 PERMIT NO: 110329 JOB ADDRESS: 7300 W 44TH AVE DESCRIPTION: Demo former gas station and *** CONTACTS *** owner 303/235-2806 sub 303/421-3366 ** P~RCEL INFO ** ZONE CODE: UA SUBDIVISION: UA City of Wheat Ridge Jim Gochis ISSUED: EXPIRES: 04/01/2011 03/31/2012 asphault parking lot per plans Urban Renewal C/O Steve Art 02-0761 Alpine Demolition USE: BLOCK/LOT#: UA 0/ ** FEE SUMMARY ** ESTIMATED PROJECT VALUATION: 111,448.00 Demolition Fee Total Valuation ** TOTAL ** Conditions: Subject to field inspections. FEES 50.00 .00 50.00 I, by my signature, do hereby attest that the work to be performed shall comply ""itll all accompanying approved plans and i.fications, applicable building codes, and all applicable municipal codes, policies and procedures, and that 1 am the . owner or have been authOrized by the legal mmer of the property and am autl10rlzed to obtain this permit and perionn the WOr)~ described and approved in conjunction ~llth this permit. I further attest that I am legally authorized to include all entities named within this document as parties to the work to be performed and that all '.','Qrlc to be performed is disclosed in this document and/or its' accompanying approved plans and specifications. Signature of Dl'iNER Dr CONTR~CTOR (Clrcle one) uate 1. This permit Ivas issued based on the information provided in the pennit application and accompanying plans and specifications and is subject to the compliance with those documents, and all 3pplicable statutes, ord.Lllances, regulations, policies and procedUres. 2. This pennie shall expire 365 days after tile date of issuance regardless of activity. Requests for extenS.Lon \]lust be made in writing and received prior to tile date of expiration. An extension of no more than 180 days made be gl-c!f1ted at the discretion of the Chief Building Official and may be subject to a fee equal to one-half of the original pennit. [e" 3, If this permit expires, a new permit may be required to be obtained. Issuance of a new permit shall be subject ta the standard requirements, fees and procedures for approval of any new pennit. Re" issuance or extension o!: expired permits is at the sole discretion of the Chief Building Official and ~s not guaraIlteed. 4, No worl~ of any manner shall be performed that shall results in a change of the natural flow of wat>2r without prior and specific approval. 5. The permit holder shall notify the Building and Inspection Services Division in accordance with established policy of all required inspections and shall not proceed or conceal ".Iork vlithout written approval of sucl1 worl~ f::om the Building and Inspectlon Services Divlsion. 6. The issuance or granting of a permit shall not be construed to be a pennlt for, or an appraval of, any violation o[ applicable code or any ordinance or regulation o[ t11is jurisdiction. p,pproval of 'dark is SUbJect Signature o[ '/ ief ",Birilding Offical /, INSPECTIGN REQUEST LINE, (303)234-5933 REQUESTS MUST BE MADE BY 3PM .~ BUSINESS Date BUILDING OFFICE: (303) 235-2855 DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY. City of Wheat Ridge COinmercial Demolitlo PERMIT -110413 PERMIT NO, 110413 JOB ADDRESS, 7340 W 44TH AVE DESCRIPTION, Demo other 1/2 of antique mall *** CONTACTS *** owner 303/235-2806 sub 303/421-3366 ** PARCEL INFO ** ZONE CODE, UA SUBDIVISION, 0351 City of Wheat Ridge Jim Gochis ISSUED, EXPIRES, 04/20/2011 04/19/2012 02-0761 Alpine Demolition USE, BLOCK/LOT#, U." 0/ ** FEE SUMMARY ** ESTIMATED PROJECT VALUATION, FEES 111,448.00 Demolition Fee Total Valuation ** TOTAL ** Conditions: Subject to field 50.00 .00 50.00 inspections. I, by my signature, do hereby attest that the work to be performed shall comply with all accompanying approved plans and f'-~i.fications, applicable building codes, and all applicable municipal codes, poliCies and procedures, and that I am t.tJe owner or have been authorized by the legal owner of the property and am authorized to obtain this permit and perform tl.~ work. described and approved in conjunction with this permit. I further attest that I am legally authorlzed to include all entities named ~lithin this document as parties to the work to be performed and that all \~or)c to be performed 1S disclosed in this document and/or its' accompanying approved plans and specifications. Signature of O\'INER or CONTRACTOR (Circle one) Date 1. This permit was issued based on the intormation provided in the permit: application "iDd accompanying plans and specifications and is subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, pOlicies and procedures. 2. This permit shall eJ-:pire 365 days after the date of issuance regardless of activi be made in writing and received prior to the date of expiration. An extension of at the discretion of the Chief Building Official and may be subject to a fee equc 3. If this permit expires, a ne\~ permit may be required to be obtained. Issuance of the standard requirements, fees and procedures for approval of any new permit. R€ permits is at the sale discretion of the Chief Building Official and is not guarc ". No work of any manner shall be performed that shall results 1n a change of the and specific approval. 5. The permit holder shall notify the Building and Inspection Services Division i.n of all required inspecti.ons and shall not proceed or conceal Hork without \"Iritter Building and Inspection Services Dlv1sion. 6. The issuance or granting of a permit shall not be construed to be a permit for, C of any applicable code or any ordinance or regulation of this juri~ ct'V" Signature a ell I Building Offical INSPECirON ;EQUEST LINE, REQUESTS MUST BE MP~E BY Date (303)234-5933 BUILDING OFFICE, ( 3PM 1'.NY BUSINESS DAY FOR INSPECTION CITY OF WHEAT RiDGE 04/20/11 1,17 PI1 odbb Alpine Demolition RECEIPT NO,CDB0060BB BPSP Demo other 1/2 of ,n 110413 Demolition Fee PAYMENT RECEIVED CI( 2064 TOTAL AMOUNT 50.00 58.00 AMOUNT 50.00 50.00 F\LE COpy DEMOLITION NOTIFICATION APPLICATION FORM APPLICATION FEE MUST ACCOMPANY THIS FORM INCOMPLETE APPLICATIONS WILL BE RETURNED Submit form 10· Permit Coordinator Colorado Dept. of Public Health and Environment APCO-IE-Bl 4300 Cherry Creek Drive South ·orado Department of Public Health and Environment (Notice will be mailed to the demolition contractor unless specified otherwise) t9f5 Fee: $50 + $5 per 1000 ft' of area to be demolished = $ /15/ Denver, CO 80246-1530 Phone: 303-692-3100 Fax: 303-782-0278 Asbestos@state.co.u5 k ~ e ~ " o o " o :e "0 E Cl) Cl k "'-0 o '" ~ ~>(J '" 0 '" OJ E k .QQ)c wo::o < 0 ~ .8 t.l Q) c.. U> ..s " U) .2 o~ -'" w (J Il>t;: .c .-w'!:: < OJ '0 0 OJ t;:: 1:: Q) o k tnkO ,,0_ 0_ ..... (J (See instruction #1 on reverse side) Project Manager: A1.-1 ') LL Cell Phone # / / L/ _S-=:I£:\c'C)~=r<:,,-De __ j?fBr3}_f,~'t~LL __ I certify that the Certified Asbestos BUIlding lnspector-h~as Informed me about any remaining asbestos-containing materials in the facility to be demolished. C' ;t:! CIl " o :e "0 E Cl) Cl l;:""",D Ie Me! d~(ans of Demoli!ion: /6( Wrec\dng 0 Burning t 0 Implosion 0 Moving 0 Other, specify: t Burning requires additional authorization -Please call (303) 692-3100 and ask to s eak to the 0 en Burnin Permit Coordinator With my signature below, I certify th I P ssess current AHERA accreditation and state of Colorado certification as an Asbestos Building Inspector.-I also certify that I have thoroughly inspected the facility to be demolished, as listed in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the facility_* I also certify that I have informed the owner/operator of the facility or the demolition contractor that any asbestos-containing material allowed to stay in the facility must remain non-friable during demolition_ Specify type(s) of ACM remaining. below: (check appropriate box(es)): ill Vinyl asbestos floor tile (VAT) [U( VAT mastic.WI Tar/asphalt impregnat~d roofing 0 Asphaltic pipe coatings T'J Spray-a plied tar coatings 0 Caulking 0 GlaTing 0 other. s eci : J.; I . ? -.", -eJ 'I " Printed Name: Rate of Final Ifl.§ ection ExEiration Date I Cell Phone.# -"c-L 7--! (fo I verify t at all refrigerants from air conditioning/refrigeration appliances have been p perly recovered in accordance with AQCC egulation No. ·15 (for information on CFC requirements call 692-3100). I further verify that all luminous exit signs (containing radioactive material) have been disposed of in accordance with 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320). CHECK THE APPROPRIATE BOX: '0 Q) '" ~ c b ~-------------------r------------------~---------------------------,--------.---.----------------I :::l 3: c 0 Building Owner ~ 7o~'( m 0 8 ~==~~----~--~~~------------~----~~~=-------------~----~~WY~~ ___________ I Dostmark or Hand ~ate: y--a ~/ ( Approved By· . orm of Paymen! & #: C',tf-'Z-r/ 71I' Permit !I: .. Regulated asbestos-containing materials means (a) friable asbestos-co Category I nonfriable ACM that will be or has been subjected to sanding, probability of becoming or has become crumbled, pulverized, or reduced t demolition or renovation operations regulated by this regulation. Note: abated/removed prior to demolition. [~Jfnilial-310 Dlransfer-380 Record "# Date Issued: ""'~"IP-.Ji-l!,:""l!.j(t'a"""e1:A,-,C,,,"M that has become friable, (c) tIT or ra te II nonfriable ACM that has a high o e the material in the course of ......c:1"Cl1""'~\ os-containing sheet vinyl and linoleum must be properly -"'Bt V )..:1--- ~.. --, Colorado Department of Public Health and Environment Air Pollution Control Division -Indoor Environment Program -AsbestosliAQ Air Unit 4300 Cherry Creek Drive South, APCD-IE-B1 Denver, Colorado 80246-1530 Phone: 303-692-3100 -Fax: 303-782-0278 E-mail: asbestos@state.co.us DEMOLITION APPRO V AL NOTICE This approval notice is granted subject to Colorado Air Quality Control Commission Regulation No.8, Part B, adopted December 21,2007, and effective January 30,2008 and the Colorado Air Pollution Prevention and Control Act C.R.S. (25-7-101 and 25-7-501 et seq). This notice signifies that the structure was inspected for asbestos, luminous exit signs (containing radioactive material), and Ozone-Depleting Refrigerants and the demolition contractor has properly notified the Colorado Depmiment of Public Health and Environment pursuant to Regulation No.8, Pmi B. As a contractor, you may be subject to other demolition licenses and pennits, depending on the requirements of the county and municipality in which the work is being perfonned. The Colorado Department of Public Health and Environment, Air Pollution Control Division, strongly suggests that you check with county and municipal authorities in order to detennine mly other local building/pennitting requirements that must be met. Please note that certain asbestos-containing materials (ACM) may remain in the structure during demolition. Therefore, any demolition debris left behind after the completion of post- demolition site cleanup may constitute a "reason to know of asbestos-contaminated soil" at the site, subject to the requirements of Section 5.5 of the Solid Waste Regulations (6 CCR 1007-2, Part 1). THE ORIGINAL APPROVAL NOTICE MUST BE POSTED ON SITE AT ALL TIMES. Immediately Ilotify the AsbestoslIAQ Ullit of project modifications by five (number above) or e-mail (address above) and the appropriate county health department by fax. Project modificatiolls include changes ill the scope of work or the scheduled work dates, etc. This demolition approval notice is valid beginning 4121/2011. The actual scheduled work dates are from 4/2112011 through 5/5/2011. Approval issued on: 4/2112011 Record number: 77697 Fee Paid: $115.00 Notice Number: lLJE1410D For the location specified below: Antique Mall 7340 W. 44th Ave Wheat Ridge Jeffel'son County This notice has been issued to: A!pine Demolition 5790 W 56th Ave, Ste. C Arvada, CO 80002 Check number: 2078 Asbestos Building Inspector: Greg St. Louis Cerification No.: 11407 Inspection Date: 04119/2011 Colorado Department of Public Health and Environment Air Pollution Control Division -Indoor Environment Program -AsbestosllAQ Unit 4300 Cherry Creek Drive South, APCD-IE-B1 Denver, Colorado 80246-1530 Phone: 303-692-3100 -Fax: 303-782-0278 E-mail: asbestos@state.co.us ASBESTOS ABATEMENT PERMIT This pennit is granted subject to Colorado Air Quality Control Commission Regulation No.8, Part B, adopted December 21,2007, and effective January 30, 2008, !be Colorado Air Pollution Prevention and Control Act (25-7-101 or 25-7-501 et seq., C.R.S.) and the following provisions. It is only for !be purpose of allowing asbestos abatement. ADDITIONAL PERMIT PROVISIONS: By perfonning work under this pennit the abatement contractor agrees that the Division may revoke or suspend this pennit should the Division find that the contractor: o has violated or has aided and abetted in the violation of25-7-1 0 I or 25-7-50 I et seq., C.R.S. or Regulation No.8, Part B, or an order of the Division or Commission, G has failed to meet any permit and notification requirement or failed to correct any violations cited by the Division during any inspection within a reasonabje period of time, as may be detennined by the Division, • has used misrepresentation or fraud in obtaining this penn it, or, " has committed any act or omission which does not meet generally accepted standards of the practice of asbestos abatement. As a contractor, you may be subject to other licenses and pennits, depending on the requirements of the county and municipality in which the work is being performed. The Colorado Department of Public Health and Environment, Air Pollution Control Division strongly suggests that you check with county and municipal authorities in order to detelmine any other local building/permitting requirements that must be met. THE ORIGINAL PERMIT MUST BE POSTED ON SITE AT ALL TIMES. immedialely llolifY Ihe AsbeslosllAQ Ullit oj projecll1lOdijicaliolls by flL~ (l111mber above) or e-mail (address ahOl'e) alld the appropriate county health department by flU:. Project modifications include changes ill the scope of IVorl. or the scheduled IVork dates, etc. This asbestos abatement permit is valid begimring 3115/2011 tllrough 11 :59 PM on 4/13/2011. TIle actual scheduled work dates are from 3115/2011 tlll'ough 4/15/2011. Approval issued on: 317/2011 Record number: 76887 Notice Number: ll.lE0783A Variance: None Comments: None For the location specified below: Antique Mall Ground Level and East End of Building 7340 and 7350 W. 44th Ave. Wheat Ridge Jefferson County This penn it has been issued to: Alpine Demolitioll & Recycling, Inc. 5790 W. ?6th Ave, #C Arvada, CO 80002 Fee paid: $400.00 Check number: 1448 Project Supervisor: Matthew Snyder Cerification No.: 17427 Project AMS: Alexander D. Green Cerification No.: 15745 Project Manager: Issued by: LBM . City of Wheat Ridge Commercial Demolitio PERMIT -110371 PERMIT NO: 110371 JOB ADDRESS: 7350 W. 44th Ave DESCRIPTION: Demolition of existing *** CONTACTS *** owner 303/235-2806 sub 303/421-3366 ** P~~CEL INFO ** ZONE CODE: UA SUBDIVISION: UA City of Wheat Ridge Jim Gochis ISSUED: EXPIRES: building 04/08/2011 04/07/2012 02-0761 Alpine Demolition USE: BLOCK/LOT#: UA 0/ ** FEE SUMMARY ** ESTH1ATED PROJECT VALUATION: 111,448.00 Demolition Fee Total Valuation ** TOTAL ** Conditions: Approved per State Demo Permit. Subject to field inspections . FEES 50.00 .00 50.00 . lily signature, do hereby attest that the "lOr).: to be performed shall comply with all accompanying approved plans and 0;. _fications, applicable building codes, and all applicable municipal codes, polic.1es ",-nd procedures, and Ulat I am the legal owner or have been authorized by the legal owner of the property and am aut:10r.1zed to obtain thlS p,~:rrn-,-t cmd perform the l'lork described and approved in conjunction \'Iith tl1is permit. I further attest that I am legally authorized to include ,,11 entities named \.'Iithin this document as parties to the work to be performed and tiDt all '.'lOrk to be pe:cfonned is disc.losed in this document and/or its' accompanying approved plans and specifications. Signature of OHNER or CONTRACTOR (Circle one) Date 1. This permit was issued based on the information provided in the pennit application and accompanying plans and specifications and is subject to the compliance with those documents, and all applicable statutes, ordinances, regulations, policies and procedures. 2. This permit shall e:;.:pire 365 days after the date of issuance regardless of activity. Requests ror extension must be made in writing and received prior to the date of expiration. An extension of no more than 180 days made be granted at the discretion of the Chief Building Orficial and may be subject to a fee equal to one-hulf of the original permit fee. 3. If this permit expires, a ne\.'1 permit may be required to be obtained. Issuance of a ne':1 pennie shall be subject to the seandard requirements, fees and procedures for approval of any new pennie. Re-issuance o:!:' exeension of e:<:pired pennies is at the sole discretion of the Chief Building Official and is not guaranteed. ,1. No work of any manner shall be performed that shall results in a change of the natural ElOI·i of water '.~ithout prier and specific approval. 5. The permit holder shall notify the BUilding and Inspection Services Division in accoJ:"dance vlit]) eSl;abl.!.shed polj:::y of all required inspections and shall not proceed or conceal '.'Iork ~Iithoue VlJ:"iteen approval of such ~IO.r)~ feom the Building and Inspection Services Divlsion. 6. The issuance or granting of a permit shall not be construed to be a permit for, or an approval of, any violation of any provision of any applicable code or any ordinance or regulation of this jurisdiction. Approval of \'lQrk is subject to field inspection. Date signatur~ . I/v' INSPECTIO REQUEST LINE: (303) 234-5933 BUILDING OFFICE: (303) 235-2855 REQUESTS MUST BE MADE BY 3PM ANY BUSINESS DAY FOR INSPECTION THE FOLLOWING BUSINESS DAY. ':i ~~ Id Submit form 10: Permit Coordinator Colorado Depl of Public Health and Environment APCD~IE-B1 !\{ DEMOLITION NOTII" If-TION APPLICATION FORM '\ APPLICATION FE, M~tST ACCOMPANY THIS FORM _---:-=::=-__ INCOMPLETE AP ,Llq\V\TIONS WILL BE RETURNED 'ado Department (Notice will be mailed to the d~::;JJition contractor unless specified otherwise) 4300 Cherry Creek Drive South vf Public Health and Environment Fee: $50 + $5 per 1000 ft> of area to be demolished = $ ______ -' Denver, CO 80246-1530 Phone: 303-692-3100 Fax: 303-782-0278 Asbest.os@state.co.us ~ o -" III ~ -c o o c o :E o E Q) o ~ ,-0 ) 1Il_ , > " , 0 III , E ~ l m t: , 0::: 0 ( 0 ~ o -" '" a. (I) E c IJ) .2 0-_ III (I) " Illi+= .0'-(1)'1:: « '" -cO '" :;:: 'E Q) ° ~ !1 0 .8 (See instruction #1 on reverse side) Com),,)nJName: il J J Cl J' L G BuildingName:7J5_---. L. tlJ.I-r" A 17'//1/",.,. 'hiM,-,/' 1-1"", .,.. K.£c,.; 1(" AI '" '" :-' J <../ vv / j---'-V~ SC;:9D uJ .C)(,.,~~ IJ Cilyv'\ n I S,I'\te: I Zip COde:. ___ K!'YVn d 0, ~6 607JD d Telephon,e j~ J I Fax # -(PJY1 l't2i -~'3(d/l c:i,r?') 940 -0&0 '8 §~ect Manager;. I Cell Phone # ) __ ~ e.1J.?_M.x1:CJ"&\L~LGD3L?J'2 ~ L /1 'J_ J certify thai the Certified As~tsloS Building Inspector has informed me about any remaining asbestos-containing materials in the facility to be demolished. / landfill Receiving Byilding Debris: , 12sJ Puk.f.,.C-, La.v>oI k.(! " o ~ o E '" o Square foot a rge..,Of footprint of facility ':;f ~rtlon of facility to be demolished ~ OI?V \ 1-- ~~"d UIt,)dU I :c)u;tyt:~,d", 18~O$; Propos,e~ ~I~ pafe/ I Pro~~s~d Com~letion Date '-/{OI'zOII --r12-Z/Zol{ Method/Means of Demolition: .8l Wrecking 0 Burning t 0 Implosion 0 Moving 0 Other, specify: t Burning requires additional authorization -Please call (303) 692-3100 and ask to speak to the Open Burning Permit Coordinator With my signatme below, I certify that I possess current AHERA accreditation and state of Colorado certification as an Asbestos Building Inspector. I also certify that I have thoroughly inspected the facility to. be demOlished, as listed in the Demolition Site block above, sampled all suspect materials, had all samples analyzed for the presence of asbestos by a NVLAP-accredited laboratory, and have determined that no Regulated ACM exists anywhere in the facility! I also certify that I have informed the owner/operator of the facility or the demolition contractor that any asbestos-containing material allowed to stay in the facility must remain non-friable during demolition. Specify type(s) of ACM remaining, below: (check appropriate box(es): Del Vinyl asbestos floor tile (VAT) 154 VAT mastic 1M, Tar/asphalt impregnated roo~ng. 0 Asphaltic pipe coatings o Spray-applied tar coatmgs 0 Caulking 0 Glaztn tJZl Other, specify) 0 I ,; -r G:; '::';1 h 0 0, "i o~~ of Finallnspzction 7-,) -// I I verify that all refrigerants from air conditioning/refrigeration appliances have been properly recovered in accordance with AGee Regulation No. 15 (for information on CFC requirements call 692-3100). I further verify that a!lluminous exit signs (containing radioactive material) have been disposed of in accordance with 6 CCR 1007-1 subpart 3.6.4.3 (for information on luminous exit sign requirements call 303-692-3320), i m ~ ~C~H_E_C_K_T_H_E_A_P_P_R_O_P_R_tA_T_E_B_O,X_:~ ________________ ~=--------------------------,------~r----.---------------l i ~ ~ 10 Building Owner I ~ Contractor ! 0 Other I Dale: cf/OS/2-o1J 1 00 ~~~~-----------7----------------L---,,~~~--------------L-----~~~~~L-________ 1 Signature: # * Print Name: ~~ ~"'Me5 THtS Box tS FOR CDPHE USE ONLY: ---------------------~~~~~~~~~-----,---~--~=--------I )stmark or Hand Delivery Date: Approved By: I Code: 0 initial-310 0 transfer-380 " of Payment & #: Permit #: ! Record # I Date Issued: Regulated asbestos-containing matenaJs means (a) friable asbestos-containing material, (b) Category 1 nonfnable ACM that has become fnable, (c) Category I nonfriable ACM that will be or has been subjected to sanding, grinding, .Q..l,ItLing, or abrading or (d) Category II nonfriable ACM that has a high probability of becoming or has become crumbled, pulverized, or reduced 10 powder by the forces expected to act on the material in the course of demolition or renovation operations regulated by this regulation, Note: Asbestos-containing sheet vinyl and linoleum must be properly abatedlremoved prior to demolition. Colorado Department of Public Health and Environment Air Pollution Control Division -Indoor Environment Program -Asbestos/lAQ Air Unit 4300 Cherry Creek Drive South, APCD-IE-B1 Denyer, Colorado 80246-1530 Phone: 303-692-3100 -Fax: 303-782-0278 rr=::> 15' f?' ~ E-mail: asbestos@state,co,U5 ~ V:::dI lJ DEMOLITION APPROVAL NOTICE This approval notice is granted subject to Colorado Air Quality Control Commission Regulation No, 8, Part B, adopted December 21, 2007, and effective January 30, 2008 and the Colorado Air Pollution Prevention and Control Act C,R.S. (25-7-101 and 25-7-501 et seq). This notice signifies that the structure was inspected for asbestos, luminous exit signs (containing radioactive material), and Ozone-Depleting Refrigerants and the demolition contractor has properly notified the Colorado Department of Public Health and Environment pursuant to Regulation No.8, Part B. As a contractor, you may be subject to other demolition licenses and permits, depending on the requirements of the county and municipality in which the work is being perfonned. The Colorado Department of Public Health and Environment, Air Pollution Control Division, strongly suggests that you check with county and municipal authorities in order to detennine any other local building/permitting requirements that must be met. Please note that certain asbestos-containing materials (ACM) may remain in the structure during demolition. Therefore, any demolition debris left behind after the completion of post- demolition site cleanup may constitute a "reason to know of asbestos-contaminated soil" at the site, subject to the requirements of Section 5.5 of tbe Solid Waste Regulations (6 CCR 1007-2, Part 1). THE ORIGINAL APPROVAL NOTICE MUST BE POSTED ON SITE AT ALL TIMES. Immediately notify the AsbestosllAQ Unit of project modifications by fax (number above) Or e-mail (address above) and tire appropriate county Irealtlr departmellt by fax. Project modifications include changes in tire scope of work or tile scheduled lVork dates, etc. This demolition approval notice is valid beginning 4/7/2011. The actual scheduled work dates are from 4/7/2011 through 4/22/2011. Approval issued On: 4/8/2011 Record number: 77485 Fee Paid: $115,00 Notice Number: l1JE1239D For the location specified below: 7350 W. 44th Ave. 7350 W. 44th Ave. Wheat Ridge Jefferson County This notice has been issued to: Alpine Demolition 5790 W 56th Ave, Stc. C Arvada, CO 80002 89800b5[0[ : 01 Check number: 1518 Asbestos Building Inspector: Greg St. Louis Cerification No,: 11407 Inspection Date: 04/05/2011 Issued by: LBM i~~~ dSS NOIlnllOd ~I~:wOJ~ Appendix K Project Pictures Photo 1: View of Containment # 1 near waste load out. Area sample in foreground of picture. Photo 2: View of Containment #1 near Decon area. Water was stored in plastic drum for use in the shower. Photo 3: View of ACM sheet vinyl flooring that was discovered following carpet removal. The flooring was removed in Containment #3. Photo 4: View of Containment #4 exterior wall. The CMU was mechanically removed from the wall. Photo 5: View of Containment #4 from the roof. Photo 6: Photo of interior of Containment #6. This section of wall was hand demo’ed by workers on the lift. Photo 7: Worker’s loaded bricks on pallets to load into dumpsters attached to Containment #5. Photo 8: Interior view of Containment #5 durring active abatement. Photo 9: Photo of Bulb Crusher Alpine used to reduce light bulb waste Photo 10: View of worker crushing light bulbs. PPE included face shield and ½ face P-100 respirator. Photo 11: View of the east wall, south side following removal of CMU. Photo 12: Photo of the demoliton of 7350 West 44th Avenue.