Asbestos Clearance Certificate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select the date and time of the inspection

  Date

• List the name of the contractor conducting the Asbestos removal

  Yes

  No

  N/A

Inspection

• Does the contractor hold a current Asbestos Removal Licence for the Asbestos being removed?

  Yes

  No

  N/A

• Are the personnel removing the asbestos appropriately trained?

  Yes

  No

  N/A

• Is there an Asbestos Removal Plan available?

  Yes

  No

  N/A

• Is there any evidence of residual remnants of any asbestos product remaining in the excavation/work area?

  Safe

  At Risk

  N/A

• The asbestos that has been removed has it been been bagged/wrapped in accordance with How to Safely Remove Asbestos Code of Practice 2011? For example bags no more than half full, double bagged and openings "goosenecked" and sealed

  Yes

  No

  N/A

• Is, or has, the asbestos product that has been removed, been or being transported by a duly licensed Transporter?

  Yes

  No

  N/A

• List the transporter

  Yes

  No

  N/A

Inspection sign off

• An inspection has been undertaken by the undersigned of Programmed Facility Management has found that there is no visible asbestos residue remaining as a result of the asbestos removal work in the area where the asbestos removal work was performed or in the area immediately surrounding the area where the asbestos removal work was performed.

• Auditors Signature

  Sign

• Asbestos Removalist Representatives Signature

  Sign