Form24v4

• Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Where asbestos removal work requires a Class A licence, a licences asbestos assessor must carry out the clearance inspection and complete an asbestos removal clearance certificate if satisfied that the area is safe to reoccupy.

• Date and Time of Assessment:

  Date

• Report to:

• Copy to:

• Invoice to:

Client and Removal Details

• PCBU:

• Client:

• Licensed Asbestos Supervisor/Removalist

• Removalist Contact Name

• Removalist Contact Phone

• Removal Site Address:
  Address

• Building/Floor/Unit etc: Site Details

• Scope of Works:

  Class A

  Class B

• Comments: Detail type of asbestos removal eg textured ceiling scrape

• Date Removal Completed?

  Date

• Did you sight a copy of the Worksafe Notification?

  Yes

  No

  NA

• Is works consistent with form?

  Yes

  No

  N/A

• Did you sight copy of control plan?

  Yes

  No

  N/A

• Are works consistent with control plan?

  Yes

  No

  N/A

• DRAWING: Specific Asbestos Removal Area: include all details and drawing (pump locations, swabs taken, NPU location, transit route, areas not included etc.

  Drawing

Stage 1 - Preliminary Site Inspection: (28.4.1) The Assessor should establish the scope of the work that was carried out, inspect the asbestos removal control plan, check that decontamination facilities are still intact, operational and clean, check the enclosures integrity is still intact. The purpose is to inspect the area for obvious signs of contamination, such as leaks, burst waste bags, or debris from inadequate procedures. If debris is found it should be cleaned up by the licensed asbestos removalist or suitably trained workers. Any breaches of the enclosure should be fixed before the clearance process continues.

• Air lock and enclosure present, intact, clean, dry and suitable for the work?

  Yes

  No

  N/A

• Smoke test carried out and satisfactory evidence provided?

  Yes

  No

  N/A

• Smoke Test Date:

  Date

• Adequate equipment for inspection?

  Select NPU Ladders Scaffold Adequate lighting Waste disposal Signage appropriate H-type Vacuum PPE adequate Background monitoring

  • NPU
  • Ladders
  • Scaffold
  • Adequate lighting
  • Waste disposal
  • Signage appropriate
  • H-type Vacuum
  • PPE adequate
  • Background monitoring

• Air mover (NPU) present, operational and suitable for the work?

  Yes

  No

  N/A

• Decontamination facilities provided and operational?

  Yes

  No

  N/A

• The area immediately surrounding the enclosure and waste transit route was inspected and no visible asbestos or dust and debris was found.

  Yes

  No

  N/A

• Capture photo representative of the works and clearance.

  Media

• Stage 1 Preinspection Result

  PASS

  FAIL

Stage 2 - Visual Inspection (28.4.2) The area in which the enclosure and the removal work zone was inspected and no visible asbestos or dust and debris was found.

• Enclosure Details
  Example - 3 m high x 100m long x 10m wide
  V= 3000 - 3000/3= 1000 = 10-1=9 pumps.

• Enclosure Details: Height x length x width.

• Air lock and enclosure present, intact, clean, dry and suitable for the work?

  Yes

  No

  N/A

• The area immediately within the enclosure and the area immediately surrounding the enclosure was inspected and no visible asbestos or dust and debris was found.

  PASS

  FAIL

• Exclusions (Areas of No Access)

• Capture photo representative of the works and clearance.

  Media

• Comments

• Stage 2 Visual Result

  PASS

  FAIL

Stage 3 - Air Monitoring and Dust Sampling (28.4.3) The Assessor should conduct air monitoring with dust disturbance for Class A asbestos removal work. The Assessor may conduct air monitoring for Class B removal work if the results of the visual inspection determine it necessary. NPU's should be turned off and capped while air clearance monitoring is being undertaken. If surface testing is required or recommended, it should be conducted during this stage. (See Section 28.5).

• Air monitoring was carried out

  Date

• Air mover off and sealed?

  Yes

  No

  N/A

• Air disturbance carried out?

  Yes

  No

  N/A

• Duration of air disturbance (Number of minutes)

• Number of pumps required?

• The air monitoring result was satisfactory?

  Yes - Did not exceed 0.01 f/l

  No - greater than 0.01 f/l

  Results not available at this time

• Is the air monitoring analytical report attached?

  Yes

  No

• Report number:

• Surface wipes collected?

  Yes

  No

  N/A

• Number of wipes collected?

• The surface wipes result(s) was satisfactory?

  Yes - NAD

  No - Asbestos has been detected

• Is the surface wipe analytical report attached?

  Yes

  No

  N/A

• Report number:

• Exclusions (Areas excluded from clearance)

• Can the enclosure be dismantled?

  Yes

  No

  N/A

• Stage 3 Air Monitoring and Dust Sampling Result

  PASS

  FAIL

Stage 4 - Not Carried Out The Assessor deemed the clearance complete Stage 3.

• The Assessor deemed stage 4 not required.

  Yes

  No

Stage 4 - Final Assessment

• Stage 4 (28.4.4)
  When the enclosure or work area has passed the visual inspection and / or air monitoring, and any surface wipes, the Licensed Asbestos Removalist can dismantle the enclosure.

• Stage 4 Assessment

  Date

• The area in which the enclosure was erected, the area immediately surrounding the area where the enclosure was erected, the removal work zone and waste transit route was inspected and no visible asbestos or dust and debris was found.

  Yes

  No

• No asbestos debris was present around the waste container / vehicle?

  Yes

  No

  N/A

• Stage 4 Final Assessment Result

  PASS

  FAIL

CLEARANCE DECLARATION

• Capture photo representative of inspection areas

  Media

• CAN THE AREA BE REOCCUPIED?

  Yes

  No

• I the Assessor declare that:

• I found no visible Asbestos residue from asbestos removal work in the area, or in the vicinity of the area, where the work was carried out; and

  Yes

  No

  N/A

• (If air monitoring was conducted as part of the clearance inspection), the monitoring shows the respirable fibre level does not exceed 0.01 fibres/ml; and

  Yes

  No

  N/A

• As far as can be determined from the clearance inspection, the asbestos removal area does not pose a risk to health and safety from exposure to asbestos.

  Yes

  No

  N/A

• Name of a Licenced Assessor

• Assessor Licence Number (If Applicable)

• Select date

  Date

• Assessor

  Sign

• Removalist/ Supervisor

  Sign

• Select date

  Date

• Assessor

  Sign

• Removalist/ Supervisor

  Sign