Information
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Job Site Address
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Job Number
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Work Safe Certified Surveyor
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Conducted on
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Picture of the outside of job site
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Age of the house
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Laboratory being used for testing
- Tsolum & Stable Enviromental LTD. 800A 8th street Courtenay,BC V9N 1N8 (250) 871 8638
- Other
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What lab?
Property Information
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Building Use
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Property Type
- Detached Property
- Semi Detached Property
- condo/Apartments
- Barn / Farm Building
- Shop / Office building
- Other *please note
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What level floor
- Basement
- Lvl -1
- Ground
- Lvl 1
- Lvl 2
- Lvl 3
- Lvl 4
- Lvl 5
- External
- Other *please note
- Out Building
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Is there a balcony?
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Property Occupancy
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Cause Of Work
- Fire
- Flood
- Escape of water
- Wind
- trauma
- Vandalism
- Other *please note
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General Property Condition
- Immaculate
- Good
- Fair
- Poor
- Degraded
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Risk to health
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Other job site notes and hazards
Safety and ppe
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What steps are being taken to secure area?
- Remove people from area.
- Set up warning signs.
- Warn home owners or others in building.
- Set up asbestos warning tape around work area.
- Other
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PPE used
- Half mask with p100
- Tyvek
- Steel toe boots
- Gloves
- Hepa vac
- Amended water
- Sample bags
- Other
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what other ppe
Sample
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Room /Area Name
- 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
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Room Photos *Room overview at least 3 shots of the room.
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Area / Level
- Basement
- Lvl -1
- Ground
- Lvl 1
- Lvl 2
- Lvl 3
- Lvl 4
- Lvl 5
- External
- Other *please note
- Out Building
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Location Sampled
- Ceiling
- Floor
- Walls
- External
- Pipe/gutters
- Roof
- Other (please note)
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Are there multiple layers
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What material is the ceiling?
- Plasterboard
- Lath & plaster
- Concrete
- Other *please note
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Material Tested
- Floor vinyl tiles
- Floor vinyl sheets
- Insulation
- Drywall compound
- Ceiling tiles
- Leveling compound
- Mastic material
- Other *please note
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Does the flooring run under anything (cabinets, vanity’s, material)
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Does the flooring run under anything (cabinets, vanity’s, material)
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Does the flooring run under anything (cabinets, vanity’s, material)
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Time of sample taken
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Sample numbers
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How Many Samples Taken?
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Has the sample location been marked and sealed
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Has the sample location been marked on a map
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Reasoning for taking the sample
- 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.
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Reasoning for taking from that location
- Material to be removed from this location. So material must be tested before removal.
- work to be done around this location.
- Other
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Description of the sample taking process
- 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
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What steps was taken to make the process adhere to ALARA
- 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
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picture of sample locations
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SQFT of sampled material
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SQFT of sampled material to be removed