Date of Request:
OCCUPATIONAL AND ENVIRONMENTAL SAFETY OFFICE
ASBESTOS AND LEAD BASED PAINT SURVEY REQUEST
FROM: FPDC Facilities Planning Design and Construction
E&O Engineering and Operations
OUA Office of University Architect
FMD Facilities Management Department
1. Project Name:
2. Project Manager:
3. Project Work Order Number:
4. Project Location:
5. Project Start Date:
6. Project Completion Date:
7. Drawings Provided? Yes No
8. Project Description:
9. Asbestos Locations to check: 10. Lead Based Paint Locations to check:
Floor (under carpet) Fire Doors Interior walls All interior components
Above ceiling Equipment Exterior walls All exterior components
Ceiling AHV Interior windows Other (specify)
Walls (Panels, Covering) Ductwork Exterior windows
Pipes Other (specify) Interior trim
Crawlspace Exterior trim
11. Asbestos/Lead Identification and Estimated Cost:
12. Air Monitoring Estimated Allowance for Asbestos Removal:
Inspector Signature: Date:
Project Manager Signature: Date: