Ripple Rock Restorations DKI - Asbestos Survey

• Job Site Address

• Job Number

• Work Safe Certified Surveyor

  Cullen Welychko

• Conducted on

  Date

• Picture of the outside of job site

  Media

• Age of the house

• Laboratory being used for testing

  Select Tsolum & Stable Enviromental LTD. 800A 8th street Courtenay,BC V9N 1N8 (250) 871 8638 Other

  • Tsolum & Stable Enviromental LTD. 800A 8th street Courtenay,BC V9N 1N8 (250) 871 8638
  • Other

• What lab?

• Building Use

  Residential

  Commercial

  Industrial

  Other *please note

• Property Type

  Select Detached Property Semi Detached Property condo/Apartments Barn / Farm Building Shop / Office building Other *please note

  • Detached Property
  • Semi Detached Property
  • condo/Apartments
  • Barn / Farm Building
  • Shop / Office building
  • Other *please note

• What level floor

  Select Basement Lvl -1 Ground Lvl 1 Lvl 2 Lvl 3 Lvl 4 Lvl 5 External Other *please note Out Building

  • Basement
  • Lvl -1
  • Ground
  • Lvl 1
  • Lvl 2
  • Lvl 3
  • Lvl 4
  • Lvl 5
  • External
  • Other *please note
  • Out Building

• Is there a balcony?

  Yes

  No

• Property Occupancy

  Home Owner living on site

  Property Vacant

  Renter on site

  Commercial site

  Other *please note

• Cause Of Work

  Select Fire Flood Escape of water Wind trauma Vandalism Other *please note

  • Fire
  • Flood
  • Escape of water
  • Wind
  • trauma
  • Vandalism
  • Other *please note

• General Property Condition

  Select Immaculate Good Fair Poor Degraded

  • Immaculate
  • Good
  • Fair
  • Poor
  • Degraded

• Risk to health

  Noticable risks

  Structural Defect

  Stability concerns

  Other risks

  Safe

• Other job site notes and hazards

  Yes

  No

Safety and ppe

• What steps are being taken to secure area?

  Select Remove people from area. Set up warning signs. Warn home owners or others in building. Set up asbestos warning tape around work area. Other

  • Remove people from area.
  • Set up warning signs.
  • Warn home owners or others in building.
  • Set up asbestos warning tape around work area.
  • Other

• PPE used

  Select Half mask with p100 Tyvek Steel toe boots Gloves Hepa vac Amended water Sample bags Other

  • Half mask with p100
  • Tyvek
  • Steel toe boots
  • Gloves
  • Hepa vac
  • Amended water
  • Sample bags
  • Other

• what other ppe

Sample

• Room /Area Name

  Select WC Bathroom ensuite Lounge / Living Room Kitchen Utility Pantry Hallway Landing Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Bedroom 5 Office/study Dressing Room Porch Garage Out Building Loft / Attic Cupboard Built in wardrobe Other *please note

  • WC
  • Bathroom
  • ensuite
  • Lounge / Living Room
  • Kitchen
  • Utility
  • Pantry
  • Hallway
  • Landing
  • Bedroom 1
  • Bedroom 2
  • Bedroom 3
  • Bedroom 4
  • Bedroom 5
  • Office/study
  • Dressing Room
  • Porch
  • Garage
  • Out Building
  • Loft / Attic
  • Cupboard
  • Built in wardrobe
  • Other *please note

• Room Photos *Room overview at least 3 shots of the room.

  Media

• Area / Level

  Select Basement Lvl -1 Ground Lvl 1 Lvl 2 Lvl 3 Lvl 4 Lvl 5 External Other *please note Out Building

  • Basement
  • Lvl -1
  • Ground
  • Lvl 1
  • Lvl 2
  • Lvl 3
  • Lvl 4
  • Lvl 5
  • External
  • Other *please note
  • Out Building

• Location Sampled

  Select Ceiling Floor Walls External Pipe/gutters Roof Other (please note)

  • Ceiling
  • Floor
  • Walls
  • External
  • Pipe/gutters
  • Roof
  • Other (please note)

• Are there multiple layers

  Yes

  No

• What material is the ceiling?

  Select Plasterboard Lath & plaster Concrete Other *please note

  • Plasterboard
  • Lath & plaster
  • Concrete
  • Other *please note

• Material Tested

  Select Floor vinyl tiles Floor vinyl sheets Insulation Drywall compound Ceiling tiles Leveling compound Mastic material Other *please note

  • Floor vinyl tiles
  • Floor vinyl sheets
  • Insulation
  • Drywall compound
  • Ceiling tiles
  • Leveling compound
  • Mastic material
  • Other *please note

• Does the flooring run under anything (cabinets, vanity’s, material)

  Yes

  No

• Does the flooring run under anything (cabinets, vanity’s, material)

  Yes

  No

• Does the flooring run under anything (cabinets, vanity’s, material)

  Yes

  No

• Time of sample taken

  Date

• Sample numbers

• How Many Samples Taken?

• Has the sample location been marked and sealed

  Yes

  No

• Has the sample location been marked on a map

  Yes

  No

• Reasoning for taking the sample

  Select Age of the house. No known testing done With materials to be removed. Unknown age of house and materials. Age of house. Testing done in other areas has been positive.

  • Age of the house. No known testing done With materials to be removed.
  • Unknown age of house and materials.
  • Age of house. Testing done in other areas has been positive.

• Reasoning for taking from that location

  Select Material to be removed from this location. So material must be tested before removal. work to be done around this location. Other

  • Material to be removed from this location. So material must be tested before removal.
  • work to be done around this location.
  • Other

• Description of the sample taking process

  Select Drywall sample - set up drop sheet, sprayed amended water. Cut sample into bag, hepa vac area and clean area with amended water. Tapeover area and mark sample location. Clean tools. Drywall sample - set up hepa vac in area of sample. Sprayed amended water. Cut sample into bag. Hepa vac and clean area with amended water. Tape over sample location and mark. Clean tools. Vinyl sample - set up site protection. Sprayed amended water. Cut sample and put into bag. Clean area with amended water and rag. Cover sample location with tape and mark sample number. Clean tools. Vinyl sample - set up site protection. Set up hepa vac in sample location. Sprayed amended water. Cut sample and put into bag. Clean area with hepa vac and amended water and rag. Cover sample location with tape and mark sample number. Clean tools. Other

  • Drywall sample - set up drop sheet, sprayed amended water. Cut sample into bag, hepa vac area and clean area with amended water. Tapeover area and mark sample location. Clean tools.
  • Drywall sample - set up hepa vac in area of sample. Sprayed amended water. Cut sample into bag. Hepa vac and clean area with amended water. Tape over sample location and mark. Clean tools.
  • Vinyl sample - set up site protection. Sprayed amended water. Cut sample and put into bag. Clean area with amended water and rag. Cover sample location with tape and mark sample number. Clean tools.
  • Vinyl sample - set up site protection. Set up hepa vac in sample location. Sprayed amended water. Cut sample and put into bag. Clean area with hepa vac and amended water and rag. Cover sample location with tape and mark sample number. Clean tools.
  • Other

• What steps was taken to make the process adhere to ALARA

  Select Donned PPE. Used amended water. Used hepa vac. Cleaned tools. Removed people from area. Donned PPE. Used hepa vac. Cleaned tools. Removed people from area. Donned PPE. Used amended water. Cleaned tools. Removed people from area. Other

  • Donned PPE. Used amended water. Used hepa vac. Cleaned tools. Removed people from area.
  • Donned PPE. Used hepa vac. Cleaned tools. Removed people from area.
  • Donned PPE. Used amended water. Cleaned tools. Removed people from area.
  • Other

• picture of sample locations

  Media

• SQFT of sampled material

• SQFT of sampled material to be removed