kelsay - canby.k12.or.us€¦ · purchase order #: sample # comm ent layer # analysts physical...

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KELSAY Environmental Consulting 503 705-0514 CCB#196361 3693 SE Francis St. [email protected] ESB#8603 Portland, Oregon 97202 January 11, 2013 Wayne Layman Canby School District 1110 S Ivy St Canby, OR 97013 RE: Hazardous Materials Survey Lone Elder Grange Site Canby Oregon At your request, Kelsay Environmental performed asbestos survey at the residence located at the intersection of Lone Elder Road and Canby Marquam Highway in Canby, Oregon. The survey was conducted on August 27 th , 2013 and was performed to facilitate demolition of the vacant structure. Destructive methods were not used during the survey of this building; other materials may be concealed within wall or chases. However, exposed areas did not show evidence of any pipe insulation on domestic water lines. Seven suspect materials were collected from throughout the structure. They include: gypsum wallboard/joint compound, lay-in ceiling tiles, window glazing, sheet flooring (two types), and composition roofing shingles. One material, the sheet flooring from kitchen area tested positive for asbestos. Prior to demolition or renovation, asbestos-containing building materials are required to be removed by a certified abatement contractor or current residing owner per Department of Environmental Quality and OSHA regulations No other suspect asbestos- containing building materials were observed. The following Table summarizes positive materials their quantities and estimated abatement cost. Lead paint at the site is presumed to be present based upon the age of the structure. During abatement fluorescent light fixtures should be examined to determine if they are PCB- containing. If these fixtures do contain PCBs they must be disposed of properly based upon EPA Rules. Please find the attached tables and lab results. Should you have questions or need anything further please call me at 503-705-0514. Sincerely, Brad Kelsay Project Manager Attachments: Tables 1-2 Laboratory Results/Chain of Custody

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Page 1: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

KELSAY Environmental Consulting

503 705-0514 CCB#196361 3693 SE Francis St. [email protected] ESB#8603 Portland, Oregon 97202

January 11, 2013 Wayne Layman Canby School District 1110 S Ivy St Canby, OR 97013 RE: Hazardous Materials Survey Lone Elder Grange Site Canby Oregon

At your request, Kelsay Environmental performed asbestos survey at the residence located at the intersection of Lone Elder Road and Canby Marquam Highway in Canby, Oregon. The survey was conducted on August 27th, 2013 and was performed to facilitate demolition of the vacant structure. Destructive methods were not used during the survey of this building; other materials may be concealed within wall or chases. However, exposed areas did not show evidence of any pipe insulation on domestic water lines. Seven suspect materials were collected from throughout the structure. They include: gypsum wallboard/joint compound, lay-in ceiling tiles, window glazing, sheet flooring (two types), and composition roofing shingles. One material, the sheet flooring from kitchen area tested positive for asbestos. Prior to demolition or renovation, asbestos-containing building materials are required to be removed by a certified abatement contractor or current residing owner per Department of Environmental Quality and OSHA regulations No other suspect asbestos-containing building materials were observed. The following Table summarizes positive materials their quantities and estimated abatement cost.

Lead paint at the site is presumed to be present based upon the age of the structure. During abatement fluorescent light fixtures should be examined to determine if they are PCB-containing. If these fixtures do contain PCBs they must be disposed of properly based upon EPA Rules. Please find the attached tables and lab results. Should you have questions or need anything further please call me at 503-705-0514. Sincerely, Brad Kelsay Project Manager Attachments: Tables 1-2

Laboratory Results/Chain of Custody

Page 2: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

503 705-0514 CCB#196361 3693 SE Francis St. [email protected] ESB#8603 Portland, Oregon 97202

Page 2 Mr. Wayne Layman Re: Lone Elder Grange August 30, 2013

Table I ASBESTOS FINDINGS/QUANTITIES/COST ESTIMATE

Material Description Location Qty Observed

Cost to Abate

Sheet Flooring Kitchen Throughout Residence and Garage

200 SF $ 1,200

Subtotal $ 1,200

Contingency 10% $ 120

Clearance Air Monitoring 1 Day $ 250

Total Abatement Estimate $ 1,470

1. The above table has approximated quantities and contractors should field verify 2. Cost estimates were derived from experience, information from abatement contractors and the 2012

construction means.

Page 3: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

503 705-0514 CCB#196361 3693 SE Francis St. [email protected] ESB#8603 Portland, Oregon 97202

Page 2 Mr. Wayne Layman Re: Lone Elder Grange August 30, 2013

TABLE 1 ASBESTOS SAMPLING INVENTORY

Lone Elder Grange Site

Sample No. Material Description Location Results

5020.01-001 Sheet Flooring Square Pattern

Entry NAD

5020.01-002 Sheet Flooring Square Pattern

Bathroom NAD

5020.01-003 Sheet Flooring Speckled Pattern

Kitchen 30% Chrysotile

5020.01-004 Sheet Flooring Speckled Pattern

Kitchen 30% Chrysotile

5020.01-005 Drywall/Joint Compound Kitchen NAD

5020.01-006 Drywall/Joint Compound Bathroom NAD

5020.01-007 Gray Window Glazing Kitchen NAD

5020.01-008 Gray Window Glazing Window Near Entry NAD

5020.01-009 2x4 Lay-in Ceiling Tiles Main Room NAD

5020.01-010 2x4 Lay-in Ceiling Tiles Main Room NAD

5020.01-011 Plaster-Gray Granulated Main Room NAD

5020.01-012 Plaster-Gray Granulated Main Room NAD

5020.01-013 Plaster-Gray Granulated Main Room NAD

5020.01-014 Composition Roof Shingle Black

Roof NAD

5020.01-015 Composition Roof Shingle Black

Roof NAD

NAD-No Asbestos Detected

Page 4: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Attn:Customer Project:Reference #: Date: 8/28/2013

Analysis and Method

Discussion

Qualifications

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Materials Characterization - Bulk Asbestos AnalysisLaboratory Analysis Report - Polarized Light

Kelsay Environmental Brad Kelsay3693 SE Francis St. Portland, OR 972002

Lone Elder Grange-Canby SDCBR13082652

Summary of polarizing light microscopy (PLM / Stereomicroscopy bulk asbestos analysis) using the methods described in 40CFR Part 763 Appendix E to Subpart E (Interim and EPA 600 / R-93 / 116 (Improved). The sample is first viewed with the aid of stereomicroscopy. Numerous liquid slide preparations are created for analysis under the polarized microscope where identifications and quantifications are preformed. Calibrated liquid refractive oils are used as liquid mouting medium. These oils are used for identification (dispersion staining). A calibrated visual estimation is reported, should any asbestiform mineral be present. Other techniques such as acid washing are used in conjugation with refractive oils for detection of smaller quantities of asbestos. All asbestos percentages are based on calibrated visual estimation traceable to NIST standards for regulated of asbestos. Traceability to measurement and calibration is achieved by using known amounts and types of asbestos from standards where analyst and laboratory accuracy are measured. As little as 0.001% asbestos can be detected in favorable samples, while detection in unfavorable samples may approach the detection limit of 0.50% (well above the laboratory definition of trace).

Vermiculite containing samples may have trace amounts of actinolite-tremolite, where not found be PLM should be analyzed using TEM methods and / or water separation techniques. Suspected actinolite/vermiculite presence will be indicated through the sample comment section of this report.

Fibrous talc containing samples may even contain a related asbestos fiber known as anthophyllite. Under certain conditions the same fiber may actually contain both talc and anthophyllite (a phenomenon called intergrowth). Again, TEM detection methods are recommended. CA Labs PLM report comments will denote suspected amounts of asbestiform anthophyllite with talc, where further analysis is recommended.

Some samples (floor tiles, surfacings, etc.) may contain fibers too small to be delectable by PLM analysis and should be analyzed by TEM bulk protocols.

A "trace asbestos" will be reported if the analyst observes far less than 1% asbestos. CA Labs defines "trace asbestos" as a few fibers detected by the analyst in several preparations and will indicate as such under these circumstances.

Quantification of <1% will actually be reported as <=1% (allowable variance close to 1% is high). Such results are ideal for point counting, and the technique is mandatory for friable samples (NESHAP, Nov. 1990 and clarification letter 8 May 1991) under 1% percent asbestos and the "trace asbestos". In order to make all initial PLM reports issued from CA Labs NESHAP compliant, all <1% asbestos results (except floor tiles) will be point counted at no additional charge.

CA Labs is accredited by the National Voluntary Accreditation Program (NVLAP) for selected test methods for airborne fiber analysis (TEM), and for bulk asbestos fiber analysis (PLM). All analysts have a college degree in a natural science (geology, biology, or environmental science) or are recognized by a state professional board in one these disciplines .Extensive in-house training programs are used to augment education background of the analyst. The group leader of polarized light has received supplemental McCrone Research training for asbestos identification. This report is not covered by the scope of AIHA accreditation. Analysis performed at CA Labs, LLC 12232 Industriplex, Suite 32 Baton Rouge, LA 70809.

Baton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370LDEQ

Labs

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Page 1 of 6

Page 5: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Overview of Project Sample Material Containing Asbestos

Customer Project: Lone Elder Grange-Canby SD CA Labs Project #: CBR13082652

brown linoleum

Glossary of abbreviations (non-asbestos fibers and non-fibrous minerals):

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Sample # Layer #

Analysts Physical Description of Subsample

Asbestos type / calibrated visual estimate percent

List of Affected Building Material Types

30% Chrysotile

004 1 brown linoleum 30% Chrysotile

003 1 brown linoleum

Baton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370

LDEQ

ca - carbonategypsum - gypsumbi - binderor - organicma - matrixmi - micave - vermiculite ot - other

pe - perlitequ - quartz

fg - fiberglassmw - mineral woolwo - wollastiniteta - talcsy - syntheticce - cellulosebr - bruciteka - kaolin (clay)

pa - palygorskite (clay)

This report relates to the items tested. This report is not to be used by the customer to claim product certification, approval or endorsement by NVLAP, NIST, AIHA LAP, LLC, or any other agency of the federal government. This report may not be reproduced except in full without written permission from CA Labs. These results are submitted pursuant to CA Labs' current terms and sale, condition of sale, including the company's standard warranty and limitations of liability provisions and no responsibility or liability is assumed for the manner in which the results are used or interpreted. Unless notified in writing to return the samples covered by this report, CA Labs will store the samples for a period of ninety (90) days before discarding. A shipping or handling fee may be assessed for the return of any samples.

Labs

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Page 6: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Polarized Light Asbestiform Materials Characterization

Customer Info: Attn: Customer Project:

8/28/20138/28/2013

Phone # None GivenFax #

______________

Laboratory Director

Chris Williams

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Brad Kelsay CA Labs Project #:Kelsay Environmental

Lone Elder Grange-Canby SD

CBR130826523693 SE Francis St. Portland, OR 972002 Date:

Turnaround Time: Samples Received: 503-705-0514 24 hrs Date Of Sampling:

Purchase Order #: Sample # Comm

entLayer

#Analysts Physical Description of Subsample

Homo-geneous (Y/N)

Asbestos type / calibrated visual estimate percent

Non-asbestos fiber type / percent

Non-fibrous type / percent

001 1 tan linoleum y None Detected10% fg25% ce 65% qu,ca

002 1 tan linoleum y None Detected10% fg25% ce 65% qu,ca

5 2 yellow mastic

003 1 brown linoleum y 30% Chrysotile 5% ce 65% qu,ca

004 1 brown linoleum y 30% Chrysotile 5% ce 65% qu,ca

4 2 yellow mastic

005 1 yellow surfaced white compound n None Detected 100% bi,mi,caBaton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370

LDEQAnalysis Method: Interim (40CFR Part 763 Appendix E to Subpart E) / Improved (EPA-600 / R-93/116)

Preparation Method: HCL acid washing for carbonate based samples, chemical reduction for organically bound components, oil immersion for identification of asbestos types by dispersion attaining / becke line method.

ca - carbonategypsum - gypsumbi - binderor - organicma - matrix

mi - micave - vermiculite ot -otherpe - perlitequ - quartz

fg - fiberglassmw - mineral woolwo - wollastiniteta - talcsy - synthetic

ce - cellulosebr - bruciteka - kaolin (clay)pa - palygorskite (clay) Approved Signatories:

___________ ______________

Alicia Stretz Senior AnalystAnalyst Alicia Stretz

1. Fire Damage significant fiber damage - reported percentages reflect unaltered fibers 2. Fire Damage no significant fiber damages effecting fibrous percentages 3. Actinolite in association with Vermiculite 4. Layer not analyzed - attached to previous positive layer and contamination is suspected 5. Not enough sample to analyze

6. Anthophyllite in association with Fibrous Talc 7. Contamination suspected from other building materials8. Favorable scenario for water separation on vermiculite for possible analysis by another method9. < 1% Result point counted positive10. TEM analysis suggested

Labs

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Page 3 of 6

Page 7: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Polarized Light Asbestiform Materials Characterization

Customer Info: Attn: Customer Project:

8/28/20138/28/2013

Phone # None GivenFax #

______________

Laboratory Director

Chris Williams

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Brad Kelsay CA Labs Project #:Kelsay Environmental

Lone Elder Grange-Canby SD

CBR130826523693 SE Francis St. Portland, OR 972002 Date:

Turnaround Time: Samples Received: 503-705-0514 24 hrs Date Of Sampling:

Purchase Order #: Sample # Comm

entLayer

#Analysts Physical Description of Subsample

Homo-geneous (Y/N)

Asbestos type / calibrated visual estimate percent

Non-asbestos fiber type / percent

Non-fibrous type / percent

2 white compound (beneath tape) y None Detected 100% mi,ca

3 white drywall with paper n None Detected 8% ce 92% qu,gy

006 1 yellow surfaced white compound n None Detected 100% bi,qu,pe,ca

2 white drywall with paper n None Detected 8% ce 92% qu,gy

007 1 red surfaced white sealant n None Detected 2% wo 98% qu,bi,ca

008 1 red surfaced white sealant n None Detected 2% wo 98% qu,bi,ca

009 1 white surfacing y None Detected 100% qu,biBaton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370

LDEQAnalysis Method: Interim (40CFR Part 763 Appendix E to Subpart E) / Improved (EPA-600 / R-93/116)

Preparation Method: HCL acid washing for carbonate based samples, chemical reduction for organically bound components, oil immersion for identification of asbestos types by dispersion attaining / becke line method.

ca - carbonategypsum - gypsumbi - binderor - organicma - matrix

mi - micave - vermiculite ot -otherpe - perlitequ - quartz

fg - fiberglassmw - mineral woolwo - wollastiniteta - talcsy - synthetic

ce - cellulosebr - bruciteka - kaolin (clay)pa - palygorskite (clay) Approved Signatories:

___________ ______________

Alicia Stretz Senior AnalystAnalyst Alicia Stretz

1. Fire Damage significant fiber damage - reported percentages reflect unaltered fibers 2. Fire Damage no significant fiber damages effecting fibrous percentages 3. Actinolite in association with Vermiculite 4. Layer not analyzed - attached to previous positive layer and contamination is suspected 5. Not enough sample to analyze

6. Anthophyllite in association with Fibrous Talc 7. Contamination suspected from other building materials8. Favorable scenario for water separation on vermiculite for possible analysis by another method9. < 1% Result point counted positive10. TEM analysis suggested

Labs

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Page 4 of 6

Page 8: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Polarized Light Asbestiform Materials Characterization

Customer Info: Attn: Customer Project:

8/28/20138/28/2013

Phone # None GivenFax #

______________

Laboratory Director

Chris Williams

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Brad Kelsay CA Labs Project #:Kelsay Environmental

Lone Elder Grange-Canby SD

CBR130826523693 SE Francis St. Portland, OR 972002 Date:

Turnaround Time: Samples Received: 503-705-0514 24 hrs Date Of Sampling:

Purchase Order #: Sample # Comm

entLayer

#Analysts Physical Description of Subsample

Homo-geneous (Y/N)

Asbestos type / calibrated visual estimate percent

Non-asbestos fiber type / percent

Non-fibrous type / percent

2 tan ceiling tile y None Detected20% fg70% ce 10% qu,pe,ca

010 1 white surfacing y None Detected 100% qu,bi

2 tan ceiling tile y None Detected20% fg70% ce 10% qu,pe,ca

011 1 tan surfaced gray plaster n None Detected 4% ta 96% bi,qu,ca

012 1 tan surfaced gray plaster n None Detected 4% ta 96% bi,qu,ca

013 1 tan surfaced gray plaster n None Detected 4% ta 96% bi,qu,ca

014 1black shingle with red & white gravel y None Detected

5% fg10% ce 85% qu,bi

Baton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370

LDEQAnalysis Method: Interim (40CFR Part 763 Appendix E to Subpart E) / Improved (EPA-600 / R-93/116)

Preparation Method: HCL acid washing for carbonate based samples, chemical reduction for organically bound components, oil immersion for identification of asbestos types by dispersion attaining / becke line method.

ca - carbonategypsum - gypsumbi - binderor - organicma - matrix

mi - micave - vermiculite ot -otherpe - perlitequ - quartz

fg - fiberglassmw - mineral woolwo - wollastiniteta - talcsy - synthetic

ce - cellulosebr - bruciteka - kaolin (clay)pa - palygorskite (clay) Approved Signatories:

___________ ______________

Alicia Stretz Senior AnalystAnalyst Alicia Stretz

1. Fire Damage significant fiber damage - reported percentages reflect unaltered fibers 2. Fire Damage no significant fiber damages effecting fibrous percentages 3. Actinolite in association with Vermiculite 4. Layer not analyzed - attached to previous positive layer and contamination is suspected 5. Not enough sample to analyze

6. Anthophyllite in association with Fibrous Talc 7. Contamination suspected from other building materials8. Favorable scenario for water separation on vermiculite for possible analysis by another method9. < 1% Result point counted positive10. TEM analysis suggested

Labs

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Page 5 of 6

Page 9: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

Polarized Light Asbestiform Materials Characterization

Customer Info: Attn: Customer Project:

8/28/20138/28/2013

Phone # None GivenFax #

______________

Laboratory Director

Chris Williams

CA Labs

Dedicated to Dedicated to Dedicated to Dedicated to

QualityQualityQualityQuality

Crisp Analytical, L.L.C.1929 Old Denton RoadCarrollton, TX 75006Phone 972-242-2754Fax 972-242-2798

CA Labs, L.L.C.12232 Industriplex, Suite 32Baton Rouge, LA 70809Phone 225-751-5632Fax 225-751-5634

Brad Kelsay CA Labs Project #:Kelsay Environmental

Lone Elder Grange-Canby SD

CBR130826523693 SE Francis St. Portland, OR 972002 Date:

Turnaround Time: Samples Received: 503-705-0514 24 hrs Date Of Sampling:

Purchase Order #: Sample # Comm

entLayer

#Analysts Physical Description of Subsample

Homo-geneous (Y/N)

Asbestos type / calibrated visual estimate percent

Non-asbestos fiber type / percent

Non-fibrous type / percent

015 1black shingle with red & white gravel y None Detected

5% fg10% ce 85% qu,bi

Baton Rouge NVLAP Lab Code 200772-0 TEM/PLM TDH 30-0370

LDEQAnalysis Method: Interim (40CFR Part 763 Appendix E to Subpart E) / Improved (EPA-600 / R-93/116)

Preparation Method: HCL acid washing for carbonate based samples, chemical reduction for organically bound components, oil immersion for identification of asbestos types by dispersion attaining / becke line method.

ca - carbonategypsum - gypsumbi - binderor - organicma - matrix

mi - micave - vermiculite ot -otherpe - perlitequ - quartz

fg - fiberglassmw - mineral woolwo - wollastiniteta - talcsy - synthetic

ce - cellulosebr - bruciteka - kaolin (clay)pa - palygorskite (clay) Approved Signatories:

___________ ______________

Alicia Stretz Senior AnalystAnalyst Alicia Stretz

1. Fire Damage significant fiber damage - reported percentages reflect unaltered fibers 2. Fire Damage no significant fiber damages effecting fibrous percentages 3. Actinolite in association with Vermiculite 4. Layer not analyzed - attached to previous positive layer and contamination is suspected 5. Not enough sample to analyze

6. Anthophyllite in association with Fibrous Talc 7. Contamination suspected from other building materials8. Favorable scenario for water separation on vermiculite for possible analysis by another method9. < 1% Result point counted positive10. TEM analysis suggested

Labs

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Page 6 of 6

Page 10: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

CALabsC.A. Labs, LLC.12232 IndustriplexSuite 32Baton Rouge, LA 70809

Phone: 225-751-5632Fax: 225-751-5634Mobile: 225-993-3471

Chain of Custod

Client Name:

Client Address:

phone number:fax number:Project Number:

Contact:

Kelsay Environmental CA Labs job CBR /(

3693 SE Francis St.Portland, Oregon 97202

503 705-0514

Brad Kelsay

Billing Address:(if different)

Send Reports to: Brad Kelsay

Project Name: Lone Elder Grange-Canby SDReports Results

VIA: EMAIL X FAX VERBAL

Total # Samples Submitted:15

Total # Samples to be Analyzed:15

Material Matrix:Air / Bulk / Water

Asbestos: please call ahead for availability of all rush and/or after hours samples.TEM

Circle analysis and TA time

AHERAEPA Level IIDrinking WaterWipeMicro-vacNIOSH 7402Chatfield Bulk

TATime

4 hour8 hour16 hour24 hour2 days3 days5 days

PLMCircle analysis and TA time

ImprovedInterim

AHERA

Point Count -(NESHAPS)

TA Time

2 hour4 hour8 hour16 hour24 hour2 days3 days5 days

Optical / IAQ

Allergen Particle:tape/bulk/swabCyclex-d cassettesAir-o-cell cassettesAnderson culturesBulk/ swab culturesBacteria culturesPCM: NIOSH 7400

TATime

2 hour4 hour8 hour16 hour24 hour2 days3 days5-10 days

Lead: Circle analysis and TA time

Matrix:

TA Time:

Paint Chips8 hour

SoilIday

Air2 days

Wipes3 days

Wastewater5 days

TCLP6-10 days

Sample Information:Sample Number:

001

002003004

005

Sample Location:

Sheet Flooring Beige/ Entry

Sheet Flooring Beige/BathroorSheet Flooring 1 1/ KitchenSheet Flooring 1 1/ Kitchen

Gypsum Wallboard/Joint Com

Sample Date/Time:

n

sound

Sample Volume (L)

\data\wordpro\forms\ChainofCustody.lwp Revision 2 3/12/01

Custody Information:Samples relinquished:

Signature / Date / Time

Samples relinquished:

Pagel

Samples received

Samples received:

&/9&/I3

Signature / Date / Time

Signature / Date / Time Signature / Date / Time

Page 11: KELSAY - canby.k12.or.us€¦ · Purchase Order #: Sample # Comm ent Layer # Analysts Physical Description of Subsample Homo-geneo us (Y/N) Asbestos type / calibrated visual estimate

CALabs 12232 IndustriplexSuite 32Baton Rouge, LA 70809

Phone: 225-751-5632Fax: 225-751-5634After hours Mobile: 225-993-3471

Client Name:

Client Address:

phone number:fax number:Project Number:

Contact:

CA Labs job # CBRBilling Address:(if different)

Send Reports to:Project Name:Reports Results

VIA: EMAIL FAX VERBAL

Sample Number:

006

007UU8

009010011012013014015

Sample Location:Gypsum Wallboard/Joint Cmpd.Window Glazing Gray/KitchenWindow Glazing Gray/WindowLay-in ceiling I lie/Main Koom

Aay-in Ceiling Tile/Main Roomaster Gray Granulated/Main R

Plaster Gray Granulated/Main FPlaster Gray Granulated/Over ECompostion Shingle Two LayeiCompostion Shingle Two Laye

Sample Date/Time:

by Entry

oomoomrick Chimneys/ Under Metal Roof

Sample Volume (L)

jrs/ Under Metal Roof

For internal use:Any initial changes regarding project (indicate yes by checking line )_

Custody Information:Samples relinquished:

Samples relinquished:

Signature / Date / Time

Samples received:

Samples received:

Signature / Date / Time

Signature / Date / Time Signature / Date / Time