ࡱ> pro#` Bbjbjmm 1H1LLLLXXX8D\&2<D{gx%%%%%%%$'hW*N&] " &LL9w&($($($ vLR%($ %($($"($0 0wXF!($H$&0&($*!*($*($ rQ($Y-&&#^&  XXLLLLLL  JOHN ELIAS BALDACCI GOVERNOR David P. Littell COMMISSIONER STATE OF MAINE DEPARTMENT OF ENVIRONMENTAL PROTECTION Bulk Sampling Disclosure Form Asbestos is a naturally occurring mineral, very strong and heat resistant and has been used in many products ranging from pipe insulation to cement wallboard. Confirming that a material is an asbestos-containing material requires that samples of the material be collected by a Maine-certified Asbestos Inspector; the samples then must be analyzed by a Maine-licensed Asbestos Analytical Laboratory to determine if they are asbestos-containing. Any materials presumed to contain asbestos will be treated by the asbestos abatement contractor as an asbestos-containing material during your building renovation or demolition project. Sampling suspect asbestos materials to determine if they contain asbestos will prevent the unnecessary expense of treating non-asbestos materials as asbestos-containing materials. In instances where the likelihood is very high that the material in question is asbestos containing, (e.g., original pipe insulation or original insulation on an old boiler in an older building or home), the building owner may choose to presume that the material is asbestos and treat it as such, thereby saving the time and cost associated with sampling the suspect material. Common building materials or building components that may be asbestos-containing include, but are not limited to: pipe insulation, mudded fitting, boiler covering, tank covering, duct covering breeching covering, surfacing material, floor tiles, cementious wallboard or siding products. May it be known that the following material(s) are presumed to be Asbestos Containing Materials and for the purposes of this asbestos abatement project will be treated as such. Suspect Material Presumed to be Asbestos-ContainingLocation(s)QuantityEstimated sampling & analytical cost FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      (Attach additional pages if needed to list all materials presumed to contain asbestos.) The total cost of sampling and analyzing these presumed asbestos-containing material(s) is approximately: $ FORMTEXT   I understand that if any suspect materials associated with this asbestos abatement activity are presumed to contain asbestos, copies of this disclosure must be presented to the building owner/agent prior to the start of the asbestos abatement activity, and must be part of the permanent record for this project. I also understand that a copy of this completed form must be available upon request at the asbestos project site. Asbestos Contractor/Design Consultant:  FORMTEXT  , Project Code:  FORMTEXT       (Printed name) (Signature) (Date) Building Owner or Agent:  FORMTEXT   (Printed name)  1>?NO\]jku_S\ŷųoea\a\R\BRjt0h(h5Ujh(5U h(5h(h(CJOJQJh(h5CJOJQJaJh(h(5CJOJQJaJh@B*CJphh@B*CJphh@B*CJphhhB*CJOJQJphhB*CJ OJQJphhB*CJOJQJphhOJQJmHnHu"jhOJQJUmHnHu 1>?Nu `a~gd(gd($a$gd($da &#$+Daa$$dh$q} &#$+D.H/Ha$$dh<q`&#$+De.H/Ha$$dh<q`&#$+De.H/H^a$ &/@)ABaGS\Akd/$$Ifl\#6 F04 layt $Ifgd $Ifgd $$Ifa$gdgd(  $&(2468LNPZ\^`tvxj3h(h5Uj3h(h5Uj 3h(h5Uj1h(h5Uj\1h(h5Uj0h(h5U h(5jh(5Ujh(5UmHnHu/6^(YkdD2$$Ifl\#6 F04 layt $Ifgd $&*,@BDNPRThjlvxz|  ҲҢҒ҂rj8h(h5UjB8h(h5Uj7h(h5Uj6h(h5Uj6h(h5Uj5h(h5U h(5jh(5UmHnHujh(5Ujh4h(h5U,(*RzbYYYY $Ifgdkd4$$Ifl\#6 F04 laytDlbYYYY $Ifgdkdz7$$Ifl\#6 F04 layt246@BDFZ\^hjnp  &jD<h(h5Uj;h(h5UjX;h(h5Uj:h(h5Uj9h(h5Uj.9h(h5U h(5jh(5Ujh(5UmHnHu/lnbYYYY $Ifgdkd:$$Ifl\#6 F04 layt8`bYYYY $Ifgdkd<$$Ifl\#6 F04 layt&(*468:NPR\^`bvxzҲҢҒ҂rjAh(h5Uj@h(h5Uj"@h(h5Uj>h(h5Ujn>h(h5Uj=h(h5U h(5jh(5UmHnHujh(5Uj=h(h5U,*RbYYYY $IfgdkdZ?$$Ifl\#6 F04 layt&(*,@BDNPT()*,rtͺűͫᤘyg"j^Dh_h(5UaJh(5aJmHnHu"jCh_h(5UaJjh(5UaJ h(5aJ h(CJh(mHnHujBhUjh(Uh(jAh(h5U h(5jh(5Ujh(5UmHnHu"RT*+,b]XSXXX]Xgd(gd(gd(kdA$$Ifl\#6 F04 layt 68jl@@ @ @@@(@)@*@+@@@@۶ۧҝ۝y`0jh(hCJOJQJUaJmHnHuh(h(CJOJQJaJh(h(aJ h(h( h(5hh(5aJUh(5aJmHnHu"jDhh(5UaJhh(5CJh(5>*aJ h(5aJjh(5UaJ!jh(5UaJmHnHu68@@)@*@+@@@@@@@@@AAAA'A(A d5$7$8$9DH$gd(gd( (Signature) (Date) If you have any questions on asbestos or state and federal regulations on asbestos, please call the Maine Department of Environmental Protections Asbestos Hazard Prevention Program at (207) 287-2651.      Bulk Sampling Disclosure 02/25/08 AUGUSTA 17 STATE HOUSE STATION BANGOR PORTLAND PRESQUE ISLE AUGUSTA, MAINE 04333-0017 106 HOGAN ROAD 312 CANCO ROAD 1235 CENTRAL DRIVE, SKYWAY PARK (207) 624-6550FAX: (207) 624-6024 BANGOR, MAINE 04401 PORTLAND, MAINE 04103 PRESQUE ISLE, MAINE 04769-2094 RAY BLDG., HOSPITAL ST. 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