NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial...

20
NOTIFICATION OF DEMOLITION Southwest Clean Air Agency 11815 NE 99th Street, Suite 1294 Vancouver, WA 98682 Voice: (360) 574-3058 Fax: (360) 576-0925 www.swcleanair.org (10 day waiting period from date submitted) (Form must be filled out completely) Notification # Must include Date Received Notification Fee $60.00 - Emergency Fee: $120.00 -- &1tr5":;ip r - --- /q-111 I MAR 1 7 2019 1. TYPE OF NOTIFICATION (•Original D Revised D Cancelled): I L - - 2 - - - 2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire Training SWCAA Reviewed JV" 3. FACILITY DESCRIPTION (Example: Residence, Barn, Carport) / Commercial Name or Description: Residence Address : 259 SW 15th Street City: Chehalis state: Wa County: Lewis Present use: Vacant Prior use: Rental 4. FACILITY INFORMATION Owner Name: Kathleen & Brad Andres Mailing Address: 9716 East Cochise Drive City: Scottsdale I State: AZ Zip Code: 85258 - I ! I I .. - J ' Contact: Raquel Robinson Phone: 360-388-0009 I - '. "- 5. NAME AND AHERA CERTIFICATION NUMBER OF ASBESTOS INSPECTOR: 6. ATIACH A COPY OF THE ASBESTOS INSPECTION REPORT Report must include laboratory name, analyst, sample type, location sample was taken and analytical method used to detect the presence of asbestos materials. 7. ASBESTOS REMOVAL CONTRACTOR (IF APPLICABLE): 0 No asbestos present , see attached AHERA Report Name: NW Abatement Services Inc Address : PO BOX 39246 City: Lakewood I State: Wa Zip Code: 98499 Contact: Chris Eckholm Phone: 253-588-0440 8. DATES ASBESTOS REMOVAL OCCURRED (mm/dd/yy) Start: _2/22/ 1 9 Complete:2/22/19 Asbestos Case Number: 19-055 9. DATES DEMOLITION WILL OCCUR (mm/dd/yy) Start: 3/31/19 Complete: 3/31/19 10. DEMOLITION CONTRACTOR or FIRE DEPARTMENT: Fire Department Name: City of Chehalis Fire Department Address : 455 NW Park city: Chehalis I State: WA county: Lewis Contact and Phone# Robert Gebhardt 360-269-3351 SWCAA FORM N0.23 REVISED 01/01/2019

Transcript of NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial...

Page 1: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

NOTIFICATION OF DEMOLITION Southwest Clean Air Agency

11815 NE 99th Street, Suite 1294 Vancouver, WA 98682

Voice: (360) 574-3058 Fax: (360) 576-0925 www.swcleanair.org

(10 day waiting period from date submitted) (Form must be filled out completely)

Notification # Must include f~ Date Received

Notification Fee $60.00 -

Emergency Fee: $120.00 --

&1tr5":;ip r - ---

/q-111 I MAR 1 7 2019 1. TYPE OF NOTIFICATION (•Original D Revised D Cancelled): I L - -

2 -- -2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire Training

SWCAA Reviewed JV"

3. FACILITY DESCRIPTION (Example: Residence, Barn, Carport) /

Commercial Name or Description: Residence

Address: 259 SW 15th Street

City: Chehalis state: Wa County: Lewis

Present use: Vacant Prior use: Rental

4. FACILITY INFORMATION

Owner Name: Kathleen & Brad Andres Mailing Address: 9716 East Cochise Drive

~

City: Scottsdale

I State: AZ Zip Code: 85258

-I

! I I .. -

J '

Contact: Raquel Robinson

Phone: 360-388-0009 I 1 ~'1 -'. -·"- ~

5. NAME AND AHERA CERTIFICATION NUMBER OF ASBESTOS INSPECTOR: KD '&~s #8'11R:PD~NES-012518-01 6. ATIACH A COPY OF THE ASBESTOS INSPECTION REPORT Report must include laboratory name, analyst, sample type, location sample was taken and analytical method used to detect the presence of asbestos materials.

7. ASBESTOS REMOVAL CONTRACTOR (IF APPLICABLE): 0 No asbestos present, see attached AHERA Report

Name: NW Abatement Services Inc Address:PO BOX 39246

City: Lakewood

I State: Wa Zip Code: 98499

Contact: Chris Eckholm

Phone: 253-588-0440

8. DATES ASBESTOS REMOVAL OCCURRED (mm/dd/yy) Start: _2/22/ 1 9 Complete:2/22/19 Asbestos Case Number: 19-055

9. DATES DEMOLITION WILL OCCUR (mm/dd/yy) Start: 3/31/19 Complete: 3/31/19

10. DEMOLITION CONTRACTOR or FIRE DEPARTMENT: Fire Department

Name: City of Chehalis Fire Department

Address: 455 NW Park

city: Chehalis I State: WA county: Lewis

Contact and Phone# Robert Gebhardt 360-269-3351

SWCAA FORM N0.23 REVISED 01/01/2019

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- - - ---- - ---- ---

11. DESCRIPTION OF PLANNED DEMOLITION WORK .• M~THODIS\ TO ~E llSEDo

Fire dept to burn home as a training exercise.

12. FUGITIVE EMISSIONS/DUST FROM DEMOLITION ACTIVITIES MUST BE CONTROLLED/PREVENTED DURING ALL PHASES OF THE PROJECT.

13. IF UNEXPECTED ASBESTOS CONTAINING MATERIAL (ACM) IS FOUND DURING DEMOLITION, STOP WORK, NOTIFY SWCAA AND CONSULT/HIRE A CERTIFIED ASBESTOS ABATEMENT CONTRACTOR.

14. IF DEMOLITION IS ORDERED BY A GOVERNMENT AGENCY, PLEASE IDENTIFY THE AGENCY BELOW:

Name: I Title:

Agency:

Date of Order (mm/dd/yy) : I Date Ordered to Begin ( mm/dd/yy ):

15. FOR EMERGENCY DEMOLITIONS: (Contact SWCAA prior to work)

Date and Hour of Emergency (mm/dd/yy) (hh/mm):

Description of the Sudden, Unexpected Event:

EXPLANATION OF HOW THE EVENT CAUSED UNSAFE CONDITIONS OR WOULD CAUSE EQUIPMENT DAMAGE OR AN UNREASONABLE BURDEN: (ATTACH ADDITIONAL PAGE IF NECESSARY)

16. I CERTIF~~~;:·;~:;~~~~N IS CORRECT. I? Jitl /l_

3/6/19 (Type or Print Name) V(Signature of Owner/Operator) (Date)

HAVE YOU PERFORMED A HAZARDOUS MATERIALS ASSESSMENT ON THE STRUCTURE?. YES 0 NO

The Washington State Dangerous Waste Regulations 0/VAC 173-303) require that demolition debris be evaluated to determine if it is dangerous. The evaluation should be completed before demolition to ensure that hazardous constituents are not released to the environment and do not present a risk to human health during or after demolition. These requirements apply to all buildings being demolished and are the responsibility of the property owner. The Washington Department of Ecology's website, https://ecology.wa.gov/Regulations-Permits/Guidance­technical-assistance/Dangerous-waste-guidance/Common-dangerous-waste/Construction-and-demolition, provides more information about the requirements and about sampling and testing construction materials to determine if they present a risk . For more information please contact a Hazardous Waste Inspector at the Washington Department of Ecology Southwest Regional Office: 360-407-6300.

SWCAA FORM N0.23 REVISED 01/01/2019

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INC .... ~ z u.I

::iE z 0 c::: > z LI.I

KD&S ENVIRONMENT AL, INC. P.O. BOX 312, MONTESANO, WA 98563

OFFICE: (360) 249-5540 FAX: (360) 249-3475 EMAIL : INFO@KDS ENY.COM

HAZARDOUS MATERIALS INVESTIGATION

ASBESTOS SURVEY

PERFORMED FOR:

DERRICK ROBINSON

PROPERTY KNOWN AS:

259 SW ism ST. C E ALIS, \VA 98321

P RFORMED BY:

j M ORAY A WILSON

HERA. CERTIFICATION: Bf1R-PD-NES -O 1251 8-0 l

December 19, 201 8

December 19, 2018 Job ff ! 8-5489

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TABLE OF CONTENTS

25~) SW 15 111 ST.

Cl-I EMALIS, \\/A 9832 J

SEClIO 1.0- SCOPE OF WORK . .. ..... . ..... .... .. .. ....... .. .... ... . . .. . .. ........ .

SECTION 2.0 -ASBESTOS-CONTAINING MATERIALS (ACM)

SURVEY SUMMARY .................................................. .

SECTION 3.0-ASSESSMENT AND RECOMMENDATIONS .................. . ........ .

SECTION 4.0 - STATEMENT OF COMPLIANCE ...................... ... .......... . .. ..

APPENDIX A

APPENDIX B

APPENDIX C

APPENDIX D

APPENDIX E

ASBESTOS SAMPLE SUMMARY

LABORATORY ANALYSIS DATA SHEETS (ASBESTOS)

PICTU RES

DRAWINGS

CERTIFICATIONS

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SECTION 1.0 SCOPE OF WORK

On Dec:i..:mber 19. 2fll8 Moraya Wilson (Bl / R-PO-~LS-012)18-0 1 ) an accredited asbestos and hazardous materials inspector for KD&S Environmental , conducted an asbestos containing materials survey of the property known as:

259SW15 111 s·1. ( lfFH \LI~~ \VA 98.12 i

The following suspect materials were investigated:

• Asbestos Containing Material

Field inspection, data collection, and report generation were based on the following Scope of Work :

1. Perform a visual inspection of the subject property to identify and inventory all accessible suspect asbestos containing materials.

2. Bulk sampling and analysis of identified suspect asbestos containing materials. 3. Provide quantity estimates of asbestos containing materials. 4. Provide a written report including sample descriptions, sample locations, and

sample location drawing.

The survey was intended to identify any possible asbestos containing materials (ACM) which may be disturbed during demolition, remodeling or maintenance activities per 40 CFR 6 1 Subpart M and to maintain compliance with WAC 296-62-07721 and current applicable Southwest Clean Air Agency (SWCAA) Regulations. KD&S Enviromnental has made a best effort attempt to identify materials, which may be disturbed. Jn addition, the asbestos survey meets the "Good Faith" asbestos inspection requirements. It should be noted that "Good Faith" surveys are limited in scope and that those materials which required destructive means to access or sample (interstitial spaces) is not included in thi s report.

Suspect asbestos containing materials within the structure \Vere identified and classified as either a surfacing material , thermal system insulation, or miscell aneous materials. Surfacing materials are those, which arc either, spray applied or troweled-on fo r acoustical, decorati ve, or fireproofing purposes . Thermal system insulation (TSI) is insulation used to inhibit heat transfer or to prevent condensation on pipes, boilers, tanks, ducts and various other components. Miscellaneous materials include all other materials · not included in the above categories such as floor tile, ceiling tile, roofing felt , cemcntitious materials, \.vallboard systems and products such as caulking, mastics and putties. 20 Miscellaneous and Surfacing samples were collected and submitted for laboratory analysis.

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Limitations of the Assessment

This targeted assessment was limited to the referenced buildings and did not include areas beyond the " foot print" of the buildings. The conclusions within th is report are prolessional opinions base solely upon visual site observations and interpretation of analytical data as described in this report. Typical construction techniques can render portions of the building inaccessible. As a result, additional ACBM may be present in inaccessible areas (i.e. within wall and ceiling cavities). Suspect ACBM within inaccessible areas shou ld be presumed to contain asbestos until characterized. The opinions presented herein apply to the site conditions existing at the time of the investigation and interpretation of current asbestos regulations. Recommendations provided may not apply to future conditions that exist at the above mention site.

Survev Methodology

The supporting documentation provided within survey report includes material summary table and the appendices that included site photographs lab analytical reports. chain of custody forms. staff certification.

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SECTION 2.0 ASBESTOS-CONTAINING MATERIALS (ACM) SUMMARY

Bulk samples collected by KD&S Enviromnental were submitted for sample analysis in

accordance with method EPA-600/R-93 / 116: " Method for the Determination of Asbestos

in Bulk Building Materials'·. Seattle Asbestos perfonned analysi s of suspect asbestos

materials. The following suspect materials were found to contain asbestos in quantities

equal to or greater than one percent ( l %).

TOT AL ASBESTOS

259S\V l5 111 S·i. l llLH \I.I~,\\.' 98~2 I

Sample Location '%ACM Descl"iption of Friable/ Total SF # Category Material Non- Friable

259-1 Utility Exterior 2% Chrysolilc Ashcstos \Vindow Nun-Fri:.1ble <3lf Round I Windo\\ Misc. Putty

259--t Exterior· I 6 1% Chrysotile Cement Asbl:'stos !\on-Friable l ,650sf Round I House Misc. Board Siding

*All sq11are.fou1av,es prul'ided are approximations and any drawings are no! lo scale. Conlrac/ors are advised to verity the 111easuremen1s on their own prior to bidding the work

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SECTION 3.0 ASSESSMENT AND RECOMMENDATIONS

ASSESSMENT

The asbestos containing materials identified in the subject property fall into the

l\rl iscellaneous Materials Category. This is an asbestos project.

RECOMMENDATIONS

All identified asbestos containing material is regulated material and must be abated prior

to any demolition or remodeling activity vhich may disturb these materials at the subject

property. A Washington State Certified Asbestos Contractor must conduct abatement of

asbestos containing materials. The asbestos containing materials identified in the subject

property fall into the Miscellaneous Materials Category. This is an asbestos project.

NARRATIVE Tms SINGLE STORY RESIDENTIAL STRUCTURE WAS BUILT IN 1900 AND HAS HAD A

LITTLE REMODELING DONE. IT IS NOCCUPIED AND THE ROOF IS COMPROMISED,

THEREFORE THE HO SE WILL BE DEMOLISHED. TOTAL SQUARE FOOTAGE IS

APPROXIMATELY 792 SQUARE FEET. IT IS A TWO-BEDROOM, ONE BATHROOM HOME.

THERE IS A SEPARATE STRUCTURE ON THE PROPERTY THAT APPEARS TO BE A SHOP

BUILDING, THIS IS NOT A PAHT OF THIS SURVEY.

EXTERIOR BUILDING MATERIALS ARE CEMENT ASBESTOS BOARD SIDING,

COMPOSITION ROOF AND BOTH VINYL ANO TWO (2) WOOD FRAMED WI NDOWS,

HOWEVER THE UTILITY ROOM WOOD FRAMED WI NDOW IS THE ONE WITH THE PUTTY

AND IS LESS THAN TllllE:E (3) LINEAR FEET.

INTERIOR BUILDING MATERIALS ARE CARPET, SHEET VINYL, LAMINATE WOOD AND

VINYL FLOORING. WALLS ARE SHEETROCK AND CEILINGS ARE EITHER CEILING TILES

OR SHEETROCK.

OF THE TWENTY (20) SAMPLES TAKEN, TWO (2) TESTED POSITIVE; THE CEMENT

ASBESTOS SIDING AND THE WINDOW PUTTY FROM THE UTILITY ROOM WINDOW. THIS IS

AN ASBESTOS PROJECT AND MUST BE ABATED PRIOR TO DEMOLITION.

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SECTION 4.0 STATEMENT OF COMPLIANCE

In accordance with W.A.C. 296-62-07721 and current applicable ORCCA Regulations, KO& S Environmental Consulting performed an Asbestos Inspection of:

259 SW 15 111 S1. lllEH \l IS, WA 98321

Abatement of asbestos-containing materials must be conducted by a Washington State Certified Asbestos Abatement Contractor. Should employees or contract personnel encounter any suspect asbestos-containing materials it is their responsibility to:

I. Contact a representative of the owner. 2. Consult the inspection report to detennine whether or not the suspect material

contains asbestos. 3. Ensure that all employees and contractors are infonned and advised of the location

and type of materials that contain asbestos.

The following asbestos-containing materials were identified at the subject property:

Sample Location %ACM Description of Friable/ Total SF # Category Material Non- Friable

25<J- I Utilit~· Exterior 2% C hr:vsotilc Ashcstos Windtm Non-Friahlc <31f Round I \Vindtm Misc. Putty

259-.t E~terior 16'% Chr~'SOtilc Cement Asbestos Non-F riable Round I I louse Misc. Board Siding

*All square foo tages provided are approximations and any drawings are not to scale. Contractors are advised lo ver{/j' the meu.rnremenls on their own prior to bidding the work.

l Hereby Attest:

l,6S0sf

The inspection report has been made avai lable to me. l wi ll inform all subcontractors of the location and types of materials containing asbestos. I am authorized to sign on behalf of my company.

Contractor: ____________ Owner' s Rep: ___________ _

Signature: Signature: _____________ _

Print Name: Print Name: ------- --- -------------Title: Title:

--------------~ ------------~

Date: Date: -------------~ --------------~

December 19, 20 18 Joh Ii 18-5489

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SAMPLE

NUMBER

259-1 Rrn '-Ii I

259-2 ROUND I

259-3 ROUND I

.~)()-.{

R<ll D I

259-1 ROUND 2

259-2 ROUND 2

259-3 ROUND2

259-4 ROUND 2

259-5 ROUND 2

259-6 Ro · •n 2

259-7 ROUND 2

259-8 ROUND 2

259-9 ROUND 2

259-10 Rou D2

259-11 Rou 'D 2

ASBESTOS SAMPLE SUMMARY 259~\\i 15 111 ST.

CH F 11 \I.I~. \\'A 98.321

MATERIAL A HERA DESCRIPTION

LOCATION CATEGORY OF MATERIAL /

ESTIMATED

QUANTITY 1-\llRhlK \ll'i< !\';Ill :-.1< 1<;

wr,u11\\ N1 ''--rRl.\BI I Wl ' . i)( l\\ Pl I I)

EXTERIOR MISC. H OUSE PAPER

H OUSE No •-FRIABLE

EXTERIOR MISC. COMPOSITION

ROOF NO -FRIAl3LE

I \ 111t1<m :\ll\\. \ ·1 II ., I \ \HI.., Ill\

H• >l \I I) I-Kl \HI I B<>IJ{,>.'11>1'-'

Krrc 1 IL: MISC. SHEET VINYL 0

FLOOR FRI AO LE TILEO W OOD

KITCHEN MISC. T !LEU DER SHEET

FLOOR NON-FRIAAl.F VINYi.ON W OOD

KITCllEN MISC. BACKSPLASI I ON

W ALL N ON-FRI!\ OLE SI IEET VINYL ON

WOOIJ

U TILITY ROOM MISC. SI IEET VINYL ON

FLOOR FRl1\l3 LE W OOD

UTILITY ROOM MISC. ROCK WOOi .

CEILJN(i No -FRIARl.E INSULATION

KITCllE MISC. CEILINCi TILE

CEJLI. G NON-FRl.l\ULE STAPLED IN PLACL:

K ITCJ-lf: i SURFACING GWB I W 1\ LL

W ALL FRIAULE O NLY

LI VI NG ROOM ENTRY MISC. CERAM IC T il.F

FLOOR NON-FRIAR! .E GROUT

LiVI NCi ROOME 1TRY MISC. FLOOR! 1Ci lJNDER

FLOOR NoN-FRli\Bl.E CERAM IC TILE

(FROM KIKllEN) LI VING ROOM MISC. CEILING TILE

CEILING ON-FRli\ULE STAPLED IN PLACE

H AL1 .W1\ Y MISC. TILE U 'DER

Fi.OOR N ON -FRIABLE L AM INAT : W OOD FLOOR! 1GON

W OOD

ASBESTOS%

2°0( IJR'r\(1JJl I

NO. E D ETECTED

NONE D ETF.CTF.O

ICl", Clll'' '.1ii111

NONE D ETECTED

NONE D ETECTED

NONE D ETECTED

ONI; D ETl'.CTEO

NONE D ETECTED

NO E D ETECTED

NCJ 11; D lTL:LTEO

NONE D ETECTED

NONE Dl-T l-:C J'ED

N ONE D l:TECT ED

N ONE D HECTEU

December 19, 2018 Job # 18-5489

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259-12 B ATHROOM Ro ND2 Fl.OUR

259- 13 BATHROOM

Rou 'D2 WALIJ CEILING

259-14 B EDROOM I ROUND2 CLOSET C EILING

259-15 BEDROOM I & ROUND 2 l-I ALLW . .\Y W ALLS

259-16 M · STER B EDROOM

Ro NO 2 W ALLS

MISC.

FRIABLE

SuRrACING

FRIABLE

MISC.

NON-FRIABLE

SURFACIN I

FRIAIJLE

SURFAC'INCi FRIARl.E

GREY SHEET

VINYL ON WOOD

SMOOHIGWB

CEILING TILE

W/FLORAL

PA'ITERN

SKIM COATO

GWB

GWB W/ SKIM

COAT SAME/\

HAI.I.WAY&

BEDROOM I

NONE DETECTED

NONE DETECTED

NONE DETECTED

NONE D ETECTED

NO E D ETECTW

Oel:cmber 19. 2018 Job Ii 18-5489

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SEATTLE ASBESTOS TEST, Lynnwood Lab· 19701 Scnber Lake Road. Suite rn3. WA 98036, Tel:425.673 9850. Fax-425 .673 9810 Bellevue Lab: 12727 Northup Way, Suite 1, Bellevue. WA 98005, Tel:425 861 111 . Fax:425.861 .11 18

Analyzing Quality

Sea!Ue Lab: 4500 9th Ave NE, Suile 300 Sea!Ue, WA 98 105 Tel 206.633 11 11 Fax:206.533.4747. Email·admin@seat!leasbestostest com

CHAIN OF CUSTODY O Bu ~ Asbestos

01 Hour

KD & S Environmental

Q POllll (.;cunt 400 Q r<o1nt (.;ounl 1000

02 Hours o ::;ame aay (4 to 6 Hrs.)

PO Box 312. Montesano. I/VA 98563

QPoint Counl Gra•;ime!ric

~I Day

rel: 360.249.5540

O Ull1er ::;pee:!',')

0 Oa1s

Fax. 360.249 3475

Number of Samples .4. PO# .. . 18-5489 (Robinson) Round 1 .. Project Location ... 259 SW 15th St, Chehalis .....

Project Manager (Check one or more) :

0 Chris Williams s;am1 1 ?.it::l~ ds.n 1w :::Jrn D Dean W ilson 360.310 .0025 ;eare: :c r.::s~r.rro .. r:·emal enm

D Ka th ie Wilson 360.310.0023 k iJ1h io@i\d ~Cfh' £QM [3 Moraya Wilson ~;il r-rj1 F. ~k:t:Js ~"\ I $;~ [!Jt:tal'8 '

D Ryan C. Wi lson s.:n.c1s;:!5Ji<.r.. :u: 'ICQTi D Sandie Pennant 360.589 .8094 :!a"c1e 1Dkose:i : c:Qm

Q# CLIENT SAMPLE # SAMPLE DESCRIPTION LOCATION NOTES

1 259·1 Window Putty Ext.

2 259·2 House Paper Ext.

3 259·3 Composition Roof Ext. Roof

4 259-4 Cement Board Siding Ext.

5

6

7

8

9

10

11

1 2

13

14

15

16

17

18

19

20

Print Name ASi Jnature Company Date Time ~·· p Moraya Wilson . / H If I ( I ~ /I KO}- S Environmcnt\l l Ill I 12/14/2018 4: 00 AM t~c1111qu 1

Kendra Wynn ,1T L\/' '"'IM I.A/ KO & S Envi ronmontill 12/17/2018 11 :55Am UC l \l tHO I . ,,. XO & S En vi ronmental l'(CCCIVC «::I. I /~ n./1

,.--(L { I G1 I t- .- I .\ ... - Sealtla Asbestos Tos1

~na yz. u .. __, '/ r>,,, (- . .,,.~0.;:, lf . ~ S' rl · {_ .:-.... vn I'{ r. Scanle Asbes tos Test IL/ >._ ,-../ / </,'

l"(C:po1 <: ... Scalllt Asbo5 1CS To!it

-- . -. ·-- _ ,_.,, . _ ... , .. . .... . ... . ... • - .~ .. ..... .. .. ... . ... - · · - · - - · - -·... .. . ... . . .... . .,,, · ·- . , ,.. .. ....... . . .. .. ...... .. _.~, .... ,.. . .... ,.~ .... . .... _ ,,. .,.., j !J .. . ,.. ...... ... ..... .. .......... - · ... -·--·L. .. ., ..... , - ..... ·· - ·-·• .... ... ~ , .... ... ~ .... _. or 1mpl1ed r ctud.nQ w<?r:~r.:y :f l1tne ss f :i· a c :a rhC\l ar pur:;c .sr! an;j aifa.-,ty of :r,orchanlab· 1:y Sea:ita A~b-JstJs Tc~ I ~cc~p ts r.o :;gal re spor.$.t'ilil ; fer ire Duicosa ror ~·. :i,ch ire : i•cnt

Results reporting method 0 1-'none [!jEmall 01-'ICl\-up

o composi;e all wa!lcca rd sarcpies O I ext result to pnone Snndie & Mor'1YD

O P:um count % ~ r less asbe5tos :-ia;i:: \ 1 1 ~ f : · )

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SEATILE ASBESTOS TEST Lyi1n"'OOd Laborator1. 19701 Scriber Laxe RC<>d. Suite 103, Lynnwood, WA 9S036. Toi: 425.673.9850. F:u. 425.673.9310, N\/LAP Lab Code: 200765-0

Disclaimer: This report musl nol IJe used l.ly lhff d 1onl to da1m product certification, approval. or endorsement by SealUe Asbes1os Test, LLC. NVLAP. NIST, or any agency ot the Feder.ii govemmenL

Ann.:

JobJll :

Samples RfJ'C'd :

Ms. Moraya Wilson 18-5489 (Robmson) Round 1 4

CfJen1~

Oare Analyted:

""'ioc' coc.: 259 SW 151.h St Chehalis

Lab ID Client Sample ID L•ye<

1 259-1 1

2 259-2 1

3 259-3 1

4 259-4 1

ANALYTICAL LABORATORY REPORT PLM by Method EPAl600/R-93/116

KO & S Environmental

201813822

12/20/2018 SamplH An.a.lyzC!d :

PO Box 312, Montesano, WA 98563

12/1912016

Description % Asbestos Fibers Non-fibrous Components % Non.asbestos Fibers

Off-white soft 2 Chrysotile Binder, Filler, Paint 2 j cellulose material with oain t Black asphaltic None Asphalt/binder, 64 Cellulose fibrous matrial detected Filler/binder Black asphaltic None Asphalt/binder, 21 Glass fibers material with sand detected Sand Tan cementltlous 16 Chrysotile Cement/binder, 5 Cellulose material with paint Paint

Page 1 of 1

Page 14: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

SEATTLE ASBESTOS TEST, Lynnwood Lab. 19701 Scriber Lake Road. Suite 103. WP.. 98036. T:1:.:2s 673 9650. Fax-.125 673.98 10 Bellevue Lab: 12727 Northup Way. Suite 1, Bellevue. W A 98005, Tel:425 ea1 1111 , Fax:425.86 1. 1118

Analyzing Quality

seatUe Lab· 4500 9th Ave. NE. Suite 300. Seallle. WA 98105, Te1:206.633.111 1, Fax:206.633 4747. Email:[email protected]

CHAIN OF CUSTODY O Butk Asbes.tos

0 1 Mour

KO & S Environmental

O Point Count '100 O Point Count 1 ooo 02 Hours o~ame cay (4 to 6 Hrs.)

PO Box 312, Montesano, WA 98563

QPoint Count Gravimetric

('.I t Day

rel : 360.249.5540

o o lher (~pec1ty)

0 Days

Fax: 360.249.3475

Number of Samples .. . 16. PO# .. . 18-5489 (Round 2) .. Project Location .. .... 259 SW 15th St, Chehalis, WA 98321.. .. ..

Project Manager (Check one or more):

Q#

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

O Chr is Will iams

O Kathie Wilson

O Ryan C. W ilson

CLIENT SAMPLE#

259-1

259-2

259-3

259-4

259-5

259-6

259-7

259-8

259-9

259-10

259-11

259-12

259-13

259-14

259-15

360.310.0023

sandie@kdsNW CQm

sar,d • P~kdsenv co:n

O Dean W ilson

~ Moraya Wilson

O Sandie Pennant

SAMPLE DESCRIPTION

Sheet vinyl on tile on wood

Tile under sheet v inyl on wood

Backsplash on sheet vinyl on wood

Sheet vinyl on wood

Rockwool insulation

Ceiling Tile Staple in place

GWB x1 wall

Ceram ic tile grout

Flooring under ceramic tile (from kit)

Ceiling Tile Staple in place

T ile under laminate wood on wood

Sheet vinyl grey on wood

GWB Smooth

Ceiling tile w/floral pattern

Ski m coat on GWB

360.310.0025 dean1lilkdv nvq omen•al ccm

360.589.1:!094 s:1n11'e@kc•onv ccm

LOCATION NOTES

Kit Floor

Kit Floor

Kit Wall

Util Floor

Util Ceiling

Kit Ceil ing

Kit Wall

L.R Entry Floor

L.R Entry Floor

L.R. Ceiling

Hall Floor

Bthrm. Floor

Bthrm. WIC

Bdrm. 1 Closet Ceiling

Bdrm. 1 & Hall Walls

16 259-16 GWB w/sklm coat same as hall & bdrm. 1 M. Bdrm. Walls

17

18

19

20

Prin t Name I Signature Company Date Time ::1am ... .! ..

Moraya Wilson ,£ IA Vi." KO & S En vi ronmental 12119/2019 11 :30AM r..111111.iUI

Kendra Wynn l'.li.V ' n If HI/ / \ JSO a.. S Envlronmontil l 12/19/2019 2:04PM · "-·" ... ....... «!re \J 1\ \/ - KO & S Environmcnlal rl ·

• Cl\IU

I f~., .-' I \j _ i.-- ( " . ___ ,,___ ~~ u Seattle A' beslos Test hh·l!v ... is': 2 "L '""".,,rd! ,... .

(. ~,...,,,,,.. •h Seattle Asbes tos Test '" ...... ~, ....-r>/ t/ ,,. 'I'.: ; )_/ z_J I . ) ' r; ii

Cpw'" SeatUa Asbos los Test ...

... ... .... ,.,. .,.,,_ .... ,., .. .... .... ...... _. ""' .. '- .......... .......... .... ...... -· ,.. ...... ........... , ·-'" -· ·- ...... ,,_.., .............. ... ... ... ...... ~ , ... .. ,,.. ... , ... ... ............... ................ ., _._ .. .. ...... ...... - ....... ..... ~ -··r ••• .. . .. ........ ...... -"t"" _ ....... ... or •O':J)lle.:1, 1nca.r.:1~9 wan <J'lty oi filno.u fe r :i par t icL. lur p:vr:x::se a"IC worro.r.:y of merc~an1r. ::: i!1 1 y Sea1:lc As::~s to 5 Tcs1 :lCC<?PIS r~ 1egu1re-s0<:.nn1c 11i1y1or tho p!..irc:ose- !or wr cri tr.J" c:!icn!

Results reporting method· O t-none oi-ax ~ Em a il Ot-1cK-up

Sandie & Moraya 0 Cornpo~ 11e all wallboar j !>ar.iples O I c.xt rCJUll IO pnone O Point counl .... '1.:i OI lass ast~stos Paye ( 1 1 ol( 1

Page 15: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

SEATILE ASBESTOS TEST Lynnwood L,;borutorr: t 9701 Scrib~r Lake Roall . Sui10 103. Lynnwcon. W I\ 980J6. Tai· •25 67J.9e50, Fa>e: 425.673.98 10. NVtA P L..>b Cede: ~0076S-O

Disclaimer. This ropo<1 musl net be used by lhe ciienl 10 d aim product certlficaUon, approval. or ondorsemen1 by SealUe Asbestos T~sl , LLC, NVLAP, N l~T. or any agency or 1110 FederaJ government.

ANALYTICAL LABORATORY REPORT PLM by Method EPA/GOOIR-93/116

cuont KD & S Environmental

B>t<hll: 201813840

Ann.: Ms. Moraya Wilson

J ob#; 18-5489 (Round 2)

S.1mpla:i Re~'d : 16 D•le An•lyud: 12/21 /2018

259 W 15 th S t Cheha lis, WA P<ojt<t Loe.: 98321

Lab ID Clienr Sampie ID Layer

1

1 259-1 2

3

1

2 259-2 2

1 3 259-3

2

1

4 259-4 2

3

1

5 259-5 2

6 259-6 1

7 259-7 1

1

8 259-8 2

3

1

9 259-9 2

3

Descnplicn

Off-while sheet vinyl Gray fibrous material with mastic Brown brittle material

Tan sheet vinyl

Black asphaltic fibrous material with mastic Black asphaltic fibrous material with mastic and paint Brown fibrous material with oaint Beige/tan sheet vinyl Gray fibrous material with mastic Black asphaltic fibrous material Gray fibrous material Black fibrous material with glass beads Brown fibrous material with paint Off-white chalky material with paint and oaoer

Red/white ceramic

Black sandy/brittle material Gray sandy/brittle material

Yellow mastic

Tan sheet vinyl

Black asphaltic fibrous material with mastic

,.,

I

Addross: PO Box 312. Montesano. WA 98563 Oato R.caNod: 12120/201 8

Sanip~ An.l!y:ted: 16

Rov.ewcd by; Sl«!ve (Fanya:>) Zhang. ?msicent

Asbes104 Fibers Non-librous Componenls % Non-asbestas Fibers

None Vinyl/binder None detected detected

None Binder/filler. detected Mastic/binder 64 Cellulose

None Binder, Filler 2 Cellulose

detected None Vinyl/binder None detected detected

None Asphalt/binder, detected Mastic/binder. Filler

70 Cellulose

Asphalt/binder, None Mastic/binder. 66 Cellulose detected Filler, Paint

None Filler, Paint 75 Cellulose detected None

Vinyl/binder None detected detected

None Binder/filler, Cellulose, Glass detected Mastic/binder 61 fibers

None AsphaiUbinder. 63 Cellulose detected Fil ler/binder None Filler, Fine particles 187 Cellulose detected

None Fi ller. Fine

detected particles, Glass 90 Mineral wool beads

None Filler, Paint 85 Cellulose detected

None Binder/fi ller.

detected Gypsum/binder. 34 Celiulose Pa int

None Ceramic/binder None detected

detected None

Sand, Filler, Binder 3 Cellulose detected None

Sand, Filler, Binder 3 Cellulose detected None

Mastic/binder 2 Cellulose detected None

Vinyl/binder None detected detected

None AsphalVbinder, detected Mastic/binder, Fi ller 69 Cellulose

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Page 16: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

SEATTLE ASBESTOS TEST Lynnwood Laboratory: 19701 S0'11:erlako Road, Suite 103, Lynnwood, WI\ S8036, Tel. 42.5.673.9850, Fax: 425.673.9810. NVLAP Lab Coda: 200768·0

Disclaimer. lnls raper: rt-.ust not be used by the cfont le daim product certification, approval, or endorsement by SealUe Awestos Test. LLC. NVlAP. NIST, or any agency of L'le Federal govemment.

ANALYTICAL LABORATORY REPORT PLM by Method EPA/600/R·93/116

Ann.: Ms. Moraya Wilson Jobi: 18-5489 (Round 2)

Semple• R0<'d: 16

Cliont. KD & S Environmental Bmh.e: 201813840

Oate/\nolyud: 12/21 /2018

259 \/'/ 15th SI Chehalis. WA "'*'' Loe.: 98321

Lab ID Client S811ple ID Layar Desmption

9 259-9 4 Brown wood debris

10 259-10 1 Brown fibrous material with oaint

1 Gray brittle material

2 Trace clear mastic

1·1 259-11 3 Tan sheet vinyl

Black asphaltic 4 fibrous material

with mastic

5 Brown brittle material

1 Gray sheet vinyl

12 259-1 2 Gray fibrous 2 material with

mastic

1 White powdery material with oaint

13 259-13 White chalky 2 material with oaoer

14 259-14 1 Gray fibrous material with oain t Trace whi te

1 powdery material

15 259-15 with paint and oaoer

2 White chalky material with oaoer Trace white

1 powdery material

16 259-16 with paint and

loaper

2 White chalky material with oaoer

%

Add'"": PO Box 312, Montesano, WA 98563 O>to Rocweo: 12120/2018

Sempl., An olyzed: 16

Asbestos Fibers Non-fibrous Components " ,, Non-asbestos Fbels

None Wood debris 5 Cellulose

detected None Filler, Paint 92 Cellulose detected None Binder, Filler 3 Cellulose detected None Mastic/binder 2 Cellulose detected None Vinyl/binder None detected detected

None AsphalVbinder, 65 Cellulose

detected Mastic/binder, Filler

None Binder, Filler 7 Cellulose

detected None

Vinyl/binder None detected detected

None Binder/filler, 63 Cellulose detected Mastic/binder

None detected Binder. Filler. Paint 3 Cellulose

None Binder/tiller, 24 Cellulose, Glass detected Gvosum/binder fibers None Paint, Filler, Perli te 67 Cellulose detected

None detected Bimler, Fi ll er, Paim 21 Cellulose

None Binder/fil ler, 28 Cellulose, Glass detected Gvosum/binder fibers

None deiectcd Binder. Filler. Paint 20 Cellulose

None Binderifi ller, 22 Cellulose, Glass detected Gvosum/binder fibers

Page 2 of2

Page 17: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

PHOTOS:

Kitchen Backsplash on Sheet Vinyl NEGATIV E Utility Room Wood Framed Window w//\,hcstos Putty

December 19. 2018 Job # 18-5489

Page 18: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

Bedroom I NEGAT IV E Bedroom 2 NEGATIVE

December 19, 20 18 Job fl 18-5489

Page 19: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

Bdrm. 1

Closet

Closet

~th rm .

• L.R.

Derrick Robinson

259 SW 15th Street

Chehalis, WA 98321

• M. Bdrm.

Hall Util

Kit

)IC <31f Window w/ Asbestos Putty

l ,650sf CAB Siding

Closet

.........__

ack Door

Page 20: NOTIFICATION OF DEMOLITION Southwest Clean Air Agency · 2 ---2. TYPE OF OPERATION D Partial Demolition D Complete Demolition D Ordered Demolition JA , D Emergency Demolition W Fire

(/./ / _/J 5v { ~~?~rr& y< ~;-t'?~r;r~;,/?

NOW Environmental Services or Federal Way. Washington c.:crtiti es to all that

Moraya Wilson 011./01111wy _5'·11 20 /8 !wsfi1f/ill£'cl the r eq11ire111e111s o/'

AHERA BlJILDING INSPECTOR & PROJECT

DESIGNER REFRESHER I la ~ utto::ndcd and satisfactorily completed all n.;q11in.:1n.:11ts to be accredited as an

l 11sp1.:~Lor i11 ac wrdance wi th the Toxic Substance' Contro l ;\ ct Title (Section 206)

and ~() CTR 7(1 :: .\ II r1.:qttir1.:111c11b h> th· .1ccr1.:ui1ation ;1s :in Al II· R,\ liui ld ing lnsp<:clor in ;:icwru am:c 11 ith the