HomeMy WebLinkAboutMiscellaneous Specifications 2004-5-5
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A TEZ, Inc.
Environmental Remediation Asbestos/Lead/Mold/Drug Labs
CCB #64090
23525 Hwy. 99 E. Harrisburg, OR 97446
PH 541-995-6008 FX 541-995-1015
Email atez@atezinc.com
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May 5, 2004
CERTIFICATE OF COMPLETION
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SPRINGFIELD CHURCH OF THE BRETHREN
1094 MAIN ST., SPRINGFIELD, OR
A::- /O,!~\M ~ 7f1AIN -sr;
ATEZ; Inc. has successfully completed the asbestos removal of approximately 150
square feet of sheet vinyl and mastic at 1094 Main Street, Springfield, OR.
The work was completed on May 3, 2004, see attached "Ten-Day and Non-Friable
Notification of Intent to Remove or Encapsulate Asbestos in Lane County, Oregon".
All work was completed by a Oregon certified asbestos abatement supervisor and
certified asbestos abatement workers.
The work was completed without incident.
All waste is being stored securely off site a 23525 Hwy 99 E, Harrisburg, Oregon until it
is transported to Coffin Butte for disposal. At that time you will receive an ASN4 form
showing the waste was disposed of properly.
So Certified
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Attach.
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87/25/2883 89:36
.61285
LRAPA
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TEN.DAY AND NON-FRIABLE NOTIFICATION OF INTENT TO REMOVE
ORENCAPSULATE'ASBESTOS IN LANE COUNTY, OREGON
For LRAPA Usa:
Projoct
Lane Regional Air Pollution Authority
1010 M.il) Street Fee Rec'c $
Springfield, OR 97477 '
(541)736-1056, Fax: (541) 726-1205, toll free (877) 285-7272 Check II
1/ Type of Abatemant r--- - ,-
Project Category end REQUIRED Fee
I CJ Demolition D ,
Emergency Waiver [Add 50% to requiced fee) S
~ Removai $ 36 D Non-Friebie (5-Dey Notice)
I 0 Encapsulation $ 36 D Residentiei ProjeC1 (Occupied Residence, .Q.Q!. for Demoii,ion;
I 0 Renovation $ 36 0 ~ 40 lin/80 sq ft ISmell Scaie. Short Duretion) .
0 Maintenance/Repair $ 78 I&l > 40 line.r/80 square feet; ~ 260 !inear/160 square lee!
0 Other $ 312 0 > 260 linaar/160 sqft; ~ 1,300 Iinear/800 sqit
S 390 D > 1,300 lineM/BOO sqit; ~ 2,600 linearll ,600 sqit
$ 676 0 > 2,600 Iinaar/l ,600 sqft;.~ 5,000 linear/3,500 sqit
-+ Has a, survey been $ 780 0 > 5.000 linear/3,500 sqft; < 10,000 iinear/6,000 sqft
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completed? $ 1,24B .0 > 10,000 lineer/8,000 sqft; S. 26,000 lineer/16,000 sqit
Yes J8 No 0 $ 2,OBO 0 ,. 26,000 IIn..rIlB,OOO sqlt;.5 260,000 linearl\60.000 soft
$ 2,600 0 ? 260000 lina.,/160000 sqft
If Yes. By Whom1.flT'i:.l
-+ Is this a revision to a previous notification? Yes [J .'40)1;
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A8ATEMENT PR9,JECT INFORMATION
Site Neme""<;'-"'''':l,.t'co1rl ('~"ccL,,~ ~U'o('l".." .
Site Address 1''''-'11;1, \'V1,., I."" .
Locl!ltion of Asbestos.tlt the site . .
Site C.tegory: 0 school. 0 residence 0 college, 0 industrial. 0 commercial. 0 other Ch"cc l...
Start Date.JYIn.~' .." i.s:cl- Completion Date Mo.'J'" I~ Hours on Sile: 9: 0'" _ <::; ~W)
Emergency project notification requested: C1!. No. 0 Yes - Discussed with: Dete:
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Phone
_ City
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I TYPE OF ASBESTOS MATERIAL
Type & Percent of Asbestos C'h,,-uc0Wo
I Quantity of asbest~s in projeCT - is,,
'1 0 p;'pe insulation: Q tepe, 0 cementatious (ag: transite).
o valve paCKing, 1:8 mastic, ~ sheet vinyl. D other
is "'/~
;, ''In IE/stimare or ILiac. ~
, . (LJinear, is/quare or IC/uCic feet
D floor tile, 0 roofing. 0 felt. 0 sprayon,
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WORK PRACTICES AND REMOVAL PROCEDURES
o wet method, 0 dry methods with air filtering. 0 gloveb~g, (Bl contelnrr,en1. 0 nega"tive air.
" 0 HEPA vacuum, 0 vacuum truck with HEPA filter, 0 other
Ambient air monitoring to be performed: ~ yes, 0 no
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DISPOSAL PROCEDURES
o chule to dropbox. 0 hend.lo.d dropbox. 1:8 wetted and double bagged. 0 other
o waste s!Ored on site in secured container. 0 waste secured off sile aT 71S7S HWY
Ilil waste removed d.iiy, 0 other -
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.....Jj[IRRISBURG,~ II
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.I DISPOSAL SITE
I (] Short Mountain, fiil Coffin Bune, 0 other__.
I ABATEMENT CONTRACTOR
Contractor Name ATE?:. T1\lr
Mailing Address ?1.."I.?S. ""'Y ,OQ ..
Ciry HARRISBURG
Competen t Person l("'p II r r'\ r n I (j
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License No. FSC535
StBte
OR ZIP97446 Phone' (541) 995-6008
Certificate No..SI,;)', On . Cell/Pager No. ~-"-C,,J <;J <-J
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I PROPERTY OWNER
Name c/(\ IV1,. I r"11V)"'I......'"\ lt2.~los
Mailing Addrass IG",I L" ;cJ" S-\-r"~ t
City. ;;;P.i.~"-;zy...:.1 F1, "J"'<:f' t StateJ:J2...... 210 S7dcd Phone '.<'C',:'l . 1<,-,0"
N8meIPi~asepr' ]"1.~_;j~~-pn,,-v.....<"Pc'''''blj Organization l::)r,07 0)"C.
SignaTure ~.{ .~ I 0-:<'-'.~1k; t'~=:. Phone-'i"i'5_' !,;,,,co/ Date ,-II",," foci
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ASN4
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ASBESTOS WASTE SHIPMENT REPORT FORM 0 ttosLiI
PLEASE PRINT OR TYPE! If you have questions, contact your locai DEQ Regionai Office in Poniand al (503) 22,.
5364, Salem at (503) 378-8240 ext. 272, Medford at (541) 776-6010 ext. 235, or Bend at (541) 388-6146 ex{, 226, 0 R
call (800) 452-4011 for the location of your iocal regional DEQ office. '
WASTE GENERATOR: (Con<ractor, F.cili<y, or Operator) \
:, Asbeslos removal site name and address:..sf\' \ 1)( [; ,~'" C~, ~ < C \,., 1'\('
JO"i~/ r /I)/}.J/'I ~~1..j..j<Ld~OR
~ Js Scree< 7ru..-~ t.v' /<:; /031 c,!j.Is""
Comact person:.-:I",,5'~'<;::/ 7::i/'AU: 012 "7'71.11'>1 Phone:
Operator's name and address: ATEZ. INC_ Phone:
23525 HIGHWAY 99 EAST HARRISBURG, OREGON
S~el Ci~ta(e
--lId ~",<,,~k"'Af\ !~'''J'17/
J..n'W " 77~/~ &
Counry
Zip
51( / - ~:J - 90<;':;-
Waste disposal site:
OOFFIN Bl1ITE LANDFILL
Phone:
(S41 , ggS-600R
LANE 97446
County Zip
(541 ) 745-2018
BENTON 97330
Counry Zip.
28972 OOFFIN B~rrrE ROAD
roll.,!ALLIS. UKJ:k.VN
City/Slate ,
C'I. ( -n-1Cu~' <::...
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Slreet
Describe asbestos materialS: .LSJ"" ~ ~ )/~ -'-7/,
Contaums:' Number: Jt>
6.
,Toral quannry (cubic yards):
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Type: ~
17
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OPERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately
described abov,e by proper shipping name and are classified, packaged, 'marked and labeled, and are in all respects In
proper condition for transpon by highway according to all government regulations. AlI movement of.thi, asbeStos-
, containing materiai is recorded on this Waste Shipment Record Fonn. .
Name: ROBERT R.:~. p~WOO .
Signature:.d?6 ~~& ~'
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Company: _
Date:
ATEZ. INC,
7')-/2-0<1
TR.-\.:'iSPORTER(S):
~. Transponer # I: (Acknowledgment or rec t of materials)
..l".gent: 1<1 I~"no!'l' 'Q l(~1 Company:
Address 2352.5AIW):' 99 E. HARRISBl,1R(l, OR 9!i46 Phone:
Signature~R~~ ~ ~
9 Traosponer #2: (AcknOwledgment ~rial')
Agent: ~. ,,,.,, . Company:
A'l'R'7., mr
(541 )
Dace:
995-6008
'5-12 -oY
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Address:
Phone:
Signature:
Dace:
DISPOSAL: (Cenification of receipt ofasbesto, matetiais covered by thi, manifest, except as noted in item Ii beiow.)
:0 IVaste Disposal Site: OOFF~ BlJITE LANDFILL
'iame and Title: ,r), ((Ii ~ {~
Signature f{a""(T1 if f1f)~
tASHJEJ.;
. Date:' M!\ 'Y ,2 'ibG4
Phone: (541) 745-2018
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: : DISCREPANCY SPACE: (Add anachmenc, as needed)
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