HomeMy WebLinkAbout38971; HOLIDAY PARK RESTROOM REPLACEMENT; ASBESTOS ABATEMENT AND LEAD COMPONENT REMOVAL; 2006-12-18CONSULTING ENGINEERS
4180 Ruffin Rd., Ste. 115
San Diego, CA 92123
(858) 2440440 / Fax (858) 244.0441
www.w-and-k.com
V11 TO:
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FROM:
'I DATE:
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RE:
I ' Attachment:
JOB #:
Mr. Schuck,
Dale A. Schuck
City of Carlsbad Public Works
405 Oak Avenue, Carlsbad, California 92008
Jerry Sherman, Winzler & Kelly
December 18, 2006
Asbestos Abatement and Lead Component Removal at Holiday Park
Restrooms located in the City of Carlsbad, California
Project Documentation and Analytical Results (Laboratory Reports)
1038206004.77010
1-1
A
Based on the request of the City of Carlsbad Public Works, Winzler & Kelly performed air
monitoring associated with asbestos abatement activities and dust-wipe sampling associated with lead
component removal activities at the Holiday Park Restrooms located in the City of Carlsbad, California.
Asbestos abatement and lead component removal activities were performed by Raul Mendoza
Construction from October 10 to 12, 2006.
Winzler & Kelly personnel, using the National Institute for Occupational Safety and Health (NTOSH)
7400 methodology for phase contrast microscopy (PCM), analyzed' all daily progress air samples
collected prior to, during, and after abatement activities of ACMs. Winzler & Kelly field personnel are
NIOSH 582-certified for PCM analysis certified by the State of California for asbestos consultation
services. Progress air samples for asbestos were collected from within and outside each representatiTe
work area and analyzed through the use of PCM. Progress air samples revealed the airborne fiber
concentrations within work areas to be below the permissible exposure limit (PEL) of 0.1 fibers per cubic
centimeter (f/cc) of air. Progress air samples revealed the airborne fiber concentrations outside work areas
and inside the work area after abatement activities to be below the United States Environmental
Protection Agency (USEPA)'s recommended occupancy criteria, following asbestos removal activities, of
0.01 f/cc of air. Locations of the air samples are presented on the Air Sample Location Map.
Prior to, and after removal of lead-bearing substances (LBSs), dust-wipe samples for lead were collected
I by Winzler & Kelly personnel in the representative work area. Samples were transported under chain-of-
custody record to,' and analyzed by, an accredited laboratory, AmeriSci, Inc., in accordance with USEPA
Method 3050/7420 for lead.
'I
y JZLEzIKELLY ' CONSULTING ENGINEERS
Holiday Park Restrooms
December 18, 2006 I Page 2
The dust lead levels, as determined by wipe sampling, were considered acceptable when the dust lead I level was below 40 micrograms per square foot (ug/ft2) of interior floors. All work overseen by Winzler
& Kelly was performed in compliance with all applicable Federal, State, and local regulations governing
the environmental aspects of asbestos abatement and disposal. The following pages attached include
project documentation, sample results, and laboratory reports.
I Sincerely, /
I tephen1. Reese IJerryyerman Project Manager Hazardous Material Division Manager
Certified Asbestos Consultant #05-3853 Certified Asbestos Consultant #97-2324 I DHS Lead Inspector-Assessor! DHS Lead Inspector/Assessor #5809
Project Monitor #13938
I
Cleàrahce Speed. Memo
3531 E. Miraloma Avenue
Anaheim, CA 92806
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Client:
I Facility:
# WUZLESJ<ELLY
.COM S U L T I No ENO INEER S
4180 Ruffin Road, Suite 115
San Diego, CA 92123
Date:
Project Number: /1?20 79OtO
On /0 10-66Winzler & Kelly Consulting Engineers performed a visual inspection and coll
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Select One Background Air Samples
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. Background Wipe Samples
Process Wipe Samples
Process Air Samples .
Clearance Air Samples . Clearance Wipe Samples
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(Location) .
The results of the aforementioned air monitoring indicate that airborne fiber conce
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LI] 70 Structures per square millimeter (S/mm2) per the AHERA Protocol Method outlined in 40
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EPA's recommended clearance criteria of 0.01 fibers per cubic centimete
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Measured background concentrations of fibers per cubic centimeter of air (f/cc).
The results of the aforementioned wipe sarnpj.ing-results indicate
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Based on the results of the inspection and analysis the following fu
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None, containment may be removed. J None.
Re-clean the Work Area. Re-testing is required.
Other: . . . . .
Comments:.
I Analytical Method: . El AHERA Protocol
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NIOSH 7400 PCM
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LI EPA SW-846 & 3050/7420
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Print Name Signature . • .
Date
CSM 1/04 Page 1 of 1
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Clearance Speed Memo WD1ZLERcSzKELLY
CO N SUITING ENGINEERS
3531 E. Miraloma Avenue
4180 Ruffin Road, Suite 115
Aniilipiin r.4omnK
San Die2o. GA 92123
Client: C'j °¼: (-V L: Date: / U
Facility: t4 Project Number: /633 0 00L1_)C 10
On /0 _- / f• O( Winzler & Kelly Consulting Engineers performed a visual inspecti
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Background Air Samples
Background Wipe Samples
Process Air Samples Process Wipe Samples
Clearance Air Samples
Clearance Wipe Samples
From: L-tc Qk ' c
(Location)
The results of the aforementioned air monitoring indicate that airborne fiber concentrat
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Select One
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SelectAll That Apply
LIII 70 Structures per sar(millimeter (S/mm2) per the RA Protocol Method outlined in 40
CFR Part 763 Su E.
R EPA's rødinended clearance criteri 0.01 fibers per cubic centimeter of air (f/cc).
Meafd background.concentrationg of fibers per cubic centimeter of air (f/cc).
The results of the aforementioned wipe sampling results indicate that s
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. Above (Fail) HUD's recommended clearance criteria of 40 ug/fl2.
Below (Pass) '' Measured background concentrations of _ug/ft2.
Other (specify):
Based on the results of the inspection and analysis the following further actions are required:
SelectOne
None, containment may be removed. XNone.
Re-clean the Work Area. Re-testing is required.
Other:
Comments:_________________________
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I Analytical Method: Li AHERA Protocol
Other (specify):
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Print Name igna ruI
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CSM 1/04 Page 1 of 1
— — — — — — — — — — — — — — — — — —
Certificate of Analysis Form WINzLER&KELLY.
CONSULTING ENGINEERS
3531 E. Miraloma Avenue S 4180 Ruffin Road, Suite 115 Anaheim, CA 92806 San Diego, CA 92123
IWA Inside Area Client: O Date: /O .0 OWA Outside Work
HEX HEPA Exhaust Locatioñ:h/LI'i_k'?A_f-/'-- Page J_.ofL CLR Clearance
__ PER Personal
Project Number: /63 0TH Other
______ FLB Field _Blanks
Sample
Number.
Location Flow
Rate
Start
Time
Stop
Time
Total
Time
Total
Volume
Fibers!
Fields
Fiber
DenSity
(f/mm)
Fiber
Conc
ob~7 O9- /2/i) YX A7 Z/(cc LIT ô3
// 22o _____ S
CYb3 o9-; /2/5 3 %> Lf(tf. 43
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I certify that the above samples were collected and analyzed in accordance with the requirements of the NIOS14 7400 Methodology.
W&K Representate( OCA CSST Number: 032
Signature) S
Certificate of Analysis Form
0
3531 E. Miraloma Avenue 4180 Ruffin Road, Suite 115 Anaheim, CA 92806 San Diego, CA 92123
IWA Inside Area
Client: Date:HEX HEPA Exhaust
OWA Outside Work
1 CLR Clearance ,,4/I 1 Location: __/ CY-7 ' 7Y Page 4 off PER Personal
OTH Other Project Number: /O ...ôôô'-i O/O 0
FLB Field Blanks
Sample
Number.
Location Flow
Rate
(I/mm)
Start
Time
Stop
Time
Total
Time
Total
Volume
Fibers!
Fields
Fiber.
Density
(f/mm )
Fiber
Conc
(f/cc)
O o~3 3)3 3o WO /i O00
(DR b -'_
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______ ______ ____ _____
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____ ____ ______
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_______________________________ ''•
/ certify that the above samples were collected and an in accordance with the requirements of the NIOSI-I 7400 Methodology.
W&K Representative nCA /CSST Number Sign ure)
Certificate of Analysis Form u_I T 3531 E. Miraloma A venue 4180 Ruffin Road, Suite 115 Anaheim, CA 92806 San Diego, CA 92123
IWA Inside Area Client (( J' DaJô' 12 OWA Outside Work
HEX HEPA Exhaust ),Z-,-, / 1 CLR Clearance Location:y -tti( Page Of PER Personal
OTH Other Project Number: /Lt~' öL/.. '7-O(O 0 FLB Field Blanks I
Sample
Number.
Location Flow
Rate
Start
Time
Stop
Time
Total
Time
(mm)
Total
Volume
(lit)
Fibers!
Fields
Fiber
Density
(f/mm )
Fiber
Conc
(f/cc)
O3 i//3 w 9ôo o 30 700 ) ö • O OQ3 O \ LI 4L
'•• 1kLL )-0 061 5 /1/5 Eoi) qlx) 'E (1 o o (o3
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I certify that the above samples were collected and analyzed in accordance with the requirements of the NIOSH 7400 Methodology.
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W&K Representative:- ••• • SST Number-( Signaiiire)
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STORAG I I ROOF OVERHANG - I
I WOMEN'S L°
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Approximate Scale in Feet
1 L
SAMPLE LOCATION MAP
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HOLIDAY PARK RESTROOM
ADAMS STREET
CARLSBAD, CALIFORNIA a
[
PROJECT NO. DATE
AMERI Sci
Please Reply To:
ArneriSci Los Angeles
24416 S. Main Street, Ste 306
Carson, Cáflfomia 90745
TEL: (310) 834-4868 • FAX: (310) 834-4772
FACSIMILE TELECOPY TRANSMISSION
To: Steve Reese From: Minh Q. Phung
Winzler & Kelly Consulting Engineers I San Di AmeriSci Job #: 406101167
Fax #: Subject: Lead (wipe) 24 hour Results
- Client Project: 1038206004.77010; City Of
Carlsbad; Holiday Park Email: stevereese@w-and-k.com
Date: Friday, October 13, 2006 Number of Pages:
Time: 14:30:20 (including cover sheet)
Comments:
0
CONFIDENTIALITY NOTICE: Unless otherwise indicated, the information contained in this facsimile communication is confidential information
intended for use of the individual named above, lithe reader of this communication is not the intended recipient, you are hereby notified that any
dissemination, distribution or copying of this communication is prohibited. If you have received this communication in error, please Immediately notify
the sender by telephone and return the original message to the above address via the US Postal Service at our expense. Preliminary data reported here will
be verified before final report is issued. Samples are disposed of in 60 days or unless otherwise instructed by the protocol or special instructions in
writing. Thank you.
Certified Analysis Service 24 Hours A Day. 7 Days A Week Competitive Prices
visit our web site - www.ameriscl.com -
Boston • Los Angeles. New York • Richmond
I AmeriSci Los Angeles
A 4 I : 24416 S. Main Street, Ste 308
Carson, California 90745 ' IV! I
TEL: (310) 634868 • FAX: (310) 83772
AineriSci Job #: 406101167 Date Received: 10/12/06
Lead Analysis Results Date Analyzed: 10/13/06 I Dust Wipes
EPA Method 3050/7420
I Winzler & Kelly Consulting Engineers I San Di
San Diego, CA
Job Site: 1038206004.77010; City Of Carlsbad; Holiday Park I .. AmeriSci# Client Sample 0 Area Lead 406101167 Number Location (ff2) (pg/ft2) I 01 LW-001 Lead Wipe Backgrd ®Womens RR 1 22
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02 LW-002 Lead Wipe Clearance® Womens RR I <20
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• AmeilSd Reporting Limit is 20 ug.
ArneriSci does not correct sample results by the blank value. Reviewed by: CA ELAP No. 2322. AIHA Lab No. 100530. I HUD guidelines for dust wipes are:
• 40 ugl112 for floors. Analyzed by: 250 ug/f12 for interior window sills,
Minh Q. Phung
ELAP No: CA 2322 Page 1 of I • I Boston • Los Angeles New York Richmond
i
4061011.8'
I Environmental Wipe Sampling Log
I
WINZLER & KELLY CONSULTING ENGINEERS 4180 Ruffin Road, Suite 115
3531 E. Miratoma enue, Anaheim, 9280 Diego, CA 92123
Client: c:1! ~—V J £O4t Project Number: /32og,7dI
I Facility: J-~AJ Functional Space:L.,z.&et&..s ?\
Taken By: Date Sampled: ) 10 (R (a
Sample
No.
Sample
Description
Sample
Container
Sample Area Laboratory
Analysis
Required
cx\ Flame AA for Lead
LtI.tLVbf -- Rr,4 Flame AA for Lead
Flame AA for Lead
Flame AA for Lead
Flame AA for Lead
Flame AA for Lead
Flame AA for Lead
Flame AA for Lead
Chain of Possession Turnaround Time: Same Day 5 day
I
ar Title Inclusi e Date
10 1 (DIM Z. & A 11 1
igaure Title
3
Signature Title Inclusive Dates
Page nf
I
r - 4 W1NZLER&EELLY I Daily Shift Review CONSULTING ENGINEERS
3531 E Mzraloma Avenue 4180 Ruffin RoadSuzle 115
Anaheim, CA 92806 San Diego, CA 92123
I Client IL)! b C Date/Shift Name
Site Address:____1 I ________________ Project Number/ó3)OtcOo9i (6
Contractor/Foreman:
Time In:
I Time Out 2 1 3 ó No of Workers + Foreman 4F .M.
Air Samples Collected During Shift PCM Lead Air Other: L1J
Background
I Inside Work Area 11WA)
Outside Work Area (OWA)
I HEPAExhaust (1IEX
Clearance (CLR)
I Personals (PER)
'
Other(OTH)
I Field Blanks (FLB)
Total Samples Collected _ S
' Activities Conducted During Shift: 14
o4yo44g. I
)r L,aA 66 A /I J4rL 6jP1 flO1'
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Comments Related to Shift Activities/Performance:
I &6 )qi
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I W&K Representative
I
Page / iLL
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I Dai ly S ift Review WJNZLER&FELLY
CONSULTING
3531 E Miraloma Avenue 4180 Ruffin Roa4Suzle 115
I Client
Anaheim, CA 92806 . . . ..: : San Diego, CA 92123
Name LV DaWShift
Site Address C Pk.rL Projec t f/ 39 2OO
Time In £ 7Z Contractor/ForemanüO FèJ
I Time Out:- 531) . . . . No. of Workers + Foreman(3):-Lft -fF.M.
Air Samples Collected During Shift PCM Lead Air. Other L J'
Background
I Inside Work Area IWA
Outside WOrk Area (OWA) . . .
I HEPA Exhaust (HEX) . . . .. . .
.5.
. . .
Clearance (CLR) . . . . . I
I Personals (PER)
Other (0TH)
I Field Blanks (FLB) . .. . . -. .
Total Samples Collected . . ..
Activities Conducted During Shift: .
r ) ( "'1 21 L ~L -9
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: S....
I ..
I
Comments Related to Shift Activities/Performance: ..
S •.• . S
. .
.. .. S
I )
I W&K
I-
Representative Page
I
I , Daily Shift Review WINZLER&XELLY
CONSULTING
3531 E Mzraloma Avenue 4180 Ruffin Road Suite 115
Anaheim CA 92806 San Diego CA 92123
I Client /O Name Date/Shift
Site Address: Project Number
Time In Contractor/Foremanr
Time Out No of Workers + Foreman -I-FM
Air Samples Collected During Shift PCM Lead Air Other:-
Background -.
0
I Inside Work Area WA)
Outside Work Area (OWA)
I HEPA Exhaust (REX)
Clearance (CLR)
I Personals (PER) :
Other (0TH)
I Feld Blanks (FLB)
Total Samples Collected
Conducted During Shift: f r tjOov'.v i
Activities ç
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1/
I
I
Comments Related to Shift Activities/Performance:
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Page of I
W&K Representative
. 7 WINZLER&KELLY Daily Field CONSULTIForm I I N C ENGINEER S 3531 EMiraloma Avenue . . . 4180 Ruffin Road, Suite 115 Anaheim, CA 92806 San Diego, CA 92123.
Client Name: Ly 0 f 1:)
L4
. Date/Shift:
Site Address: )4€ l£1L4 P'tJL Project Number: I bO) (
REMEDIATION METHODOLOGY. UTILIZED Materials Remediated From:
Removal _Containment
- Floors - Piping Systems
- Enclosure Glove Bag - Walls Ducting Systems Encapsulation Other - Ceilings - Structural Systems
Tanks
- Boilers
Identify Specific Materials, Quantities and Locations Remediated (Estimate quantities for each day/s
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1M 'TFD Ix ILM
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PERSONAL PROTECTIVE EQUIPMENT:
RESPIRATOR TYPE RESPIRATOR MANUFACTURER
. CARTRIDGE TYPE '( 1/2 Face >/— North - Survivair
- HEPA
- Full Face
- Racal 3M P-lOO
- PAPR MSA Other
- P-95
- Supplied Air .
- P-90
- Organic Vapor
- Acid Vapor
Other__________ Stacked Cartridges: Y / N Note: Cartridges must be the same manufacturer as respirator
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DISPOSABLE COVERALLS
Number ofSuit
Boots Attached I.
Hoods Attached (J/N
PERSONAL AIR MONITORING
Personal Air Monitoring is the Responsibility of:
Contractor: IV W&K: Other:
OTHER PERSONAL PROTECTIVE EQUIPMENT $..,Hard Hats
- Rubber Boots
- Rubber Gloves
Safety Glasses
- Splash Goggles
- Harness & Line
Other_________________
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Number of Workers Monitored: 1W 11.-1N,3W\J • Results Current & Posted:
Y&
NA
I r \
W&K Representative: Pagel of
I Daily Field Form # WINZLER&KELLY
CONSULTING ENCEERS
3531 EMiraloma Avenue 4180 Ruffin Road, Suite 115 I Anaheim, CA 92806 San Diego, CA 92123
Client Name: ( L Date/Shift: I Site Address: S Project Number:
DECONTAMATIO UNIT (EExcellent, AAëceptable, F=Fail) I C!J - Clean Room Shower Room /
EF
m Number of Chambers
I
Cleanliness EI/F
VAI
Debris E/1/F
Airflow Direction E/- F / Condition of Polyethylene E I F
Excessive Water E
Breaches YIN YIN
Cold Water
Soap
I Towels ()/N
WORK PRACTICES & PROCEDURES (E=Excellent, A=Acceptable, FFail)
I
INSIDE WORK AREA OUTSIDE WORK AREA
Adequate Water Use E hA hF Visible Emissions Aj
Prompt Bagging of Debris E / / F Dumpster On-Site N
Proper Decontamination Procedures E F Dumpster is Poly Lined (J_11J /NA
I
Work Area Cleanliness E / / F Dumpster is Lockable NA
Dumpster is Labeled N/ NA
I
ENGINEERING CONTROLS
Manometer On-Site and Operational Y / "Zero Calibration" Checked
•
HEPA Filtered Vacuum On-Site & Utilized Y IN NA MANOMETER RE GS:
Hudson Sprayer On-Site & Utilized Ib 2 Time
I
Airless Sprayer On-Site & Utilized
1is1Water Hose / NA Time Reading________ Amending Agent On-Site & Utilized Y NA
Encapsulant On-Site & Utilized Y iJ1 /NA
BAG OUT
Adequate Water Utilized for Bag Out ('I '1 / NA 3 4-
Bag Out - Housekeeping Procedures 'E1 / F
I Bag Out Polyethylene Condition E // F
Breaches During Bag Out Procedures •Y )1 NA
Generator Labels on Bags/Drums Y /
I CORRECTICTIVE ACTION TAKEN Y i)
Specify Corrective Actions Taken:___________________________________________________________________
I
• COMMENTS: S •
W& Representative: Page 2 of 2
I
Daily Field L WINZLER&KELLY
CONSULTING ENGIKEERS
3531 E; Miraloma Avenue 4180 Ruffin Road, Suite 115
Anaheim, CA 92806 San Diego, CA 92123
Client: . -' Date/Shift: /6
Work Location Project Number
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Daily Field. Log
I.. 3531 E. Miraloma Avenue
Anaheim, CA 92806
Client:
I J."i Work Location: /_1
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CONSULTING ENGINEERS
4180 .Ruffin Road, Suite 115
San Diego, CA 92123
Date/ Shift:
Project Number: 10 OLOO 9
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3531 E. Miraloma Avenue
Anaheim, CA 92806
Client: 6t I\ b
Work Location: ,! /tA
WINZLER&KELLY
CONSULTING ENGICERS
4180 Ruffin Road, Suite 115
San Diego, CA 92123
Date/Shift:
Project Number: 1630,-)-o 7Cic)
$TATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF OCCUPATIONAL SAFETY
AND HEALTH Asbestos Contractors Registration Unit
I Temporary Worksite Notification for Asbestos-Related Work
I Company/Employer Name RAUL MENDOA CONSTRUICTION • INC
9058 WINTERGA.RDEN BLVD Headquarters Address:
I LAKESIDE, CA 920I0
I Contractors State License Board License Number:
DOSH Asbestos Registration Number: 800
I Address of Temporary Worksite and Precise Location:
3AS 9L qa008
I Nearest intersection:
I TypeofBusiness: C-tm' PRPk PEsrPoom
Name of the Certified Supervisor (Competent Person): RAUL NENDOZA
I Name of the Qualified Person in charge of air monitoring,
laboratory work, and respirators: V( C-ToPs IEI?fZc
I Name of Certified Asbestos Consultant (if any): tfl I t'
I
Projected job starting date: 10- 11 - otp Projected completion date: 10-13 -o(,,
Describe type, scope and work practibes of job: Pe.rnavc
I
Evaluation of potential for exposure m i. n m p,.
I
I Estimated number of employees on this job:
Prior to the start of each job or phase of asbestos-related work. requiring the
I employer or contractor to be registered, Section 341.9 of the California Co
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Regulations (8 CCR 341.9) requires notifications to the nearest DOSH District
V Office. Do not send this notification to DOSH Headquarters or to DOSH Consultation.
This will not satisfy the notification requirement and could result in citation.
Note: Any change in the information provided to the district office by the written n
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CAIJOSHA Fnrm 1RB P,f4r)flflA
t7S-TATE* OF CALIFORNIA
Division of Occupational Safety and Health
I
('Note: items marked are required)
- - -
LEAD-WORK PRE-JOB NOTIFICATION
0 Annual Notification for Steel StrUctures
Name of employer doing Lead Work Address 'Zipcode 'Phone RruL EO?V' dTUFbT)
' -R 9 - 3 1-4-
Calif. Cont. Lic. No. (ii applicable)
(3 130x 3?j
i_<e..s I b E C-tn WIC14b Pager/cellular phone no.
- 9 3 _7 ,, Supervisor: q C_TOf 'E I Ee.Ja n I F REZN FuEnTE6 Number of lead-job workers: (Check one below)
Supervisor name: FRE FuEvTE
California Department of Health Services Lead Cert. No.
(if applicable) 7021 -30
1-5
06 -10 0 ii - 20
031-40
041 -50
> 50
'Job start date/time 'Job completion date/time Shift (Check all that apply) 'Approximate duration of Lead Work in days
Day
16 -13-0(1 Swing
DGrveyard I ?) CVS
Other 'Street address or location of Job City Nearest cross street Eo'ZEJñ PL- ZLSôfl
County Zipcode Cj't- 9y3
'Precise location of work (building no., room no., etc.)
Entity contracting the lead-work (check one) Address Zipcode Phone fl remisesowner OLessee L OA)'- FVE- '1(O - Lf34 1L{
Pager/cellular phone no.
Name: aALSBF e OoB 0-171
Type of structure and use: (Check all that apply)
Dornce Building Residence Steel Structure/Type Public Access/Commercial 0 School Other
Scope of work and work practices:
'Describe lead-related work to be done (check all that apply)
Surface Preparation []Wall Repair . ICj0ther SCAP L E'#FLV1'\) Pti rT 0 Water/Moisture Damage Repair Paint Removal fJ Window/Door Repair/Replacement Demolition
'Describe paint removal methods (Check all that apply):
,
Manual Scraping/Sanding ci Demolition OHydroblasting 00ther work practices disturbing lead: Power Sanding/Grinding El Heat Guns []Torch Cutting Chemical Stripping ciAbrasive Blasting 0 Welding 'Amount of area to be disturbed: (Check one per column)
0 < 10 square feet 0 < 10 linear feet
10- 100 square feet 0 10- 100 linear fe?t
R 101 - 1000 square feet Dl 100 - 1000 linear feet
> 1000 square feet Dl > 1000 linear feet
Torch cutling/welding
Duration of work:
Concentration of lead in disturbed materials:
parts per million (ppm) I c'& I-StA r' I % percent by weight
mg/cm 2 Assumed lobe lead-containing: ED YES
Name of Notifier:
rnEnôzPt aOriSfluQTiOf) to - ii-o c
This information is provided in accordance with Title 8, California Code of Regulations, Consthction Safety Order Section-1 532.1 (p).
1/25/02
1/11/2006 12:35 519-39-59E6 RAUL MENDOZA CO PAGE 02/02
I. RAUL MENDOZA CONSTRUCTION, INC.
P.O. .Box 3O I ph (61i) 3s)O.S4 Lalces!cle, CA 02040 fax: (6 9) 3905682
RESPIRATOR FIT TEST REPORT
Name: PQy'O Hiiz_—
Type of Fit Test Used:
- Negalive/ Positive Pressure irritant Smoke
Name of Test Operator Raul Mendoza
Datéof Test: IiLL.LO(o Expiration Date:
RESPIRATOR BRAND MODEL
- SIZE PAS/FAIL
#1 t.io 1 EOQ s M.
#2 SML P/F
SML P/F
S M L P/F I
I
I
SIGNATURES:
Worker
This record indicates that you have passed or failed a qualitative fit test as shown above for the
I
particular respirator(s) shown. thertypes should not be used until fit tested.
This record must be kept for at least the duration of employment
I
I
I
11
EPA ACCREDITED
No 14412
AHERA APPROVED
OCCUPATIONAL TRAINING INSTITUTE, INC.
BE IT KNOWN TO ALL THAT
Pedro Rodrigo Martinez Arce
HAS SUCCESSFULLY COMPLETED A DAY COURSE AND, AFTER PASSING
THE REQUIRED EXAMINATION, IS AWARDED THIS CERTIFICATE
ON
August 20, 2006
FOR
ASBESTOS ABATEMENT
WORKER TRAINING
(SPANISH INSTRUCTION)
COURSE DATES: August 17-20, 2006 EXAM DATE: August 20,2006
AAWT - 3327-06
ACCREDITATION NO.
August 20, 2007
EXPIRATION DATE
Nubia
AUTH . , SIGNATURE
EXAM ISTRATOR
Nubia
For purposes of accreditationrequired oxic Substances Control
DOS H APPROVAL #CA-O 17-11
Act (TSCA)
Occupational Training Institute, Inc (Occutrain) .660 Baker St. Suite #315, Costa Mesa, CA 92626, TEL 4714.556-7844
C
SOUTH COAST MEDICAL CLINIC
408W. 8TH STREET NATIONAL CITY, CA 91950
TEL# 619474-8666, FAXH 6194744325
ASBESTOS WORKER MEDICAL CLEARANCE REPORT
I EMPLOYEE NAME ?&QWD /1'I7fleZEMPLOYEE'SSS.N i/3 -7-/S3 1
HEIGHT: 5 // WEIGHT: / Q AGE' DATE OF
I f EXAM _____MALE FEMALE ()
PHYSICIAN'S OPINION OF EMPLOYEE EXAMJNA TION
I I. HAS THE EMPLOYEE HAS BEEN EXAMINED ACCORDING TO ALL OF THE
REQUIREMENTS SET FORTH IN 29 CFR 1910.1001, 29 CFR 1910.134, AND CAC 5208j$'ES
NO() /
2. CAN THE EMPLOYEE SAFELY WEAR A NEGATIVE PRESSURE RESPIRATOR? WILL
.I
THE EMPLOYEE BE ABLE TO PERFORM HISIRER JOB NORMALLY WHILE WEARING A
EGATWE PRESSURE RESPIRATOR?
TESNO
I 3. DOES THE EMPLOYEE HAVE ANY LIMITATIONS ON TIE TASKS HE /SHE CAN
PERFORM WHILE WEARING A RESPIRATOR? ()YES NO IF YES, SPECIFY
LIMITATIONS:
oQ
- 4. DOES THE EMPLOYEE HAVE ANY MEDICAL CONDITION WHICH WOULD PLACE THE
EMPLOYEE AT INCREASED RISK OF HEALTH IMPAIRMENT FROM EXPOSURE TO
I ASBESTOS? ()YESf NO?
IF YES, EXPLAIN. /
I 5. HAVE YOU INFORMED THE EMPLOYEE, AS REQUIRED BY LAW, OF THE RESULTS OF
THE EXAMINATION AND OF ANY MEDICAL CONDITIONS THAT MAY RESULT FROM
EXPOSURE TO ASBESTOS?
I -.-) YES ( ) NO? IF YES,
-
(EXPLAIN
1 6. HAVE THE FOLLOWING EXAMINATION BEEN PERFORMED AND USED TO EVALUATE
THIS EMPLOYEE'S PRESENT MEDICAL CONDITION?
CHEST X-RAY?7ES()NOSPmOMETRYr) YES NO
PHYSICL4I1'S SIGNATU/:
ALEX K HAN M.D.
DATE I_LICENSE#: G024691
(
— — —=0=3
[&A WX
_L T %J %.I -4 EPA ACCREDITED
AHERAAPPROVED
_A0 ccvTRA
OCCUFA11ONAL TRAINING INSTITUTE, INC.
BE IT KNOWN TO ALL THAT
Daniel Robert Sarff
HAS SUCCESSFULLY COMPLETED A DAY COURSE AND, AFTER PASSING
THE REQUIRED EXAMINATION, IS AWARDED THIS CERTIFICATE
ON
August 4, 2006
FOR
ASBESTOS ABATEMENT
CONTRACTORS I SUPERVISORS
COURSE DATES July 31-Auq. 4, 2006 EXAM DATE: August 4, 2006
noersection2O6o!
EXAM ADMINISTRATOR
DOSH APPROVAL ~~CA-017-03
For purposes of accreditation required Ile Tox,c Substances Control Act (TSCA)
Occupational Training Institute. Inc (Occutrain) -660 Baker St., Suite #315, Costa Mesa, CA 92626. TEL #714-556.7844
A.ACS - 707-06
ACCREDITATION NO.
August 4, 2007
EXPIRATION DATE
ibia Aya
Paul
I
I . RAUL MENDOZA CONSTRUCTION, INC.
( P.O. Box 330 1)h. (61.9)X()&-5964 CA 92040 fax: (619) 390-5682 I Lakeside,
I
RESPiRATOR FITTEST REPORT
S.
i Name: ¶TIpi(v(\ J\
Type of Fit Test Used: Negative! Positive Pressure Irritant Smoke
I Name of Test Operator: Raul Mendoza
Date of Test: ' ) 2\ / (- (0 Expiration Date:
I RESPIRATOR BRAND MODEL SIZE PASS/FAIL
#1 Nor4-b T1OC S F I #2
- S M L P
#3 S M L P
#4 S M L P
SI ATU
I'T2t rator
I particular
This record indicates th you have passed or failed a qualitative fittest as shown above for the
respirator(s) shown. Other types should not be used until fit tested.
This record must be kept for at least the duration of employment.
I
I
I
S
I
' "M
SOTJTH COAST MEDICATUCLTMC
48W 8TH EET NATIONALcA r.
I
-:.TEL 619-4744666, FAXM 619-474-0325 ....
ASBESTOS WORKER MEDICAL CLEARANCE REPORT
I EMPLOYEE MAKE i7d.14 f_ EMPLO'YEE'S EMPLOYEE'SS.sg 2c-cc 77Oo5
I
HEIGHT;WE IGHT: AGE: DATE OF EXAM: f)f4?ysMAff FEMALE ( '212..
:
PHYSICIAN'S OPLWON OF EMPLOYEE EXAMINATION
I .HAS THE EMPLOYEE HAS BEEN EXAMINED ACCORDING T
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REQUIREMENTS SET FORTH IN 29 CFR 1910.1001,29 CFR 1910.
1
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AND CAC 5208? (/) YES NO()
CAN THE EMPLOYEE SAFELY WEAR A NEGATIVE PRESSURE
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/SHE CAN PERFORM WHILE WEARING A RESPIRATOR? ( ) YES)') NO IF YES, SPECIFY LIMITAT[ONS:___________________
4: DOES THE EMPLOYEE HAYE ANY MEDICAL CONDITION WHICH WOULD PLACE THE EMPLOYEE AT INCREASEkISK OF HEALTH IMPAIRMENT
F
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X
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IF YES, EXPLAIN
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6. HAVE THE FOLL9'1NG EXAMINATION BEEN PERFORMED A
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TI-US EM PRESENT MEDICAL CONDITIONJ, CREST X-RAY? ()YES NO SP[ROMETRY? 4' YES NO
I
. PHYSICIAN'S SIGNATURE:______________________
f J<LEXKHANMD. DATE L
_
ftLICENSE#: G024691
I
~' I
I
I
I
a-
N9 12266 EPA ACCREDITED
—A Occu"'TRAIN AHERA APPROVED
OCCUPATIONAL TRAINING INSTITUTE, INC.
BE IT KNOWN TO ALL THAT
Gerardo C. Perez
HAS SUCCESSFULLY COMPLETED A 1 DAY COURSE AND, AFTER PASSING
THE REQUIRED EXAMINATION, IS AWARDED THIS CERTIFICATE
ON
July 17, 2005
FOR
ASBESTOS ABATEMENT
CONTRACTORS / SUPERVISORS
- ANNUAL REFRESHER
COURSE DATES:
AACS-R - 3162-05
ACCREDITATION No.
July 17, 2006
EXPIRATION DATE
July 17, 2005 EXAM DATE: July 17, 2005
-'
'• \. .vJ .> L
" EATON Datid W Eaton-idmirosIraI
ev
h1jax Cediflos Ca'id'a
E *XA M ADMINISTRATOR.
. DOSH APPROVAL 4CA-017-04
aso ci aouediaz,a., required unde: secli3r, 205 at Sip Yxc.5jb1pnces Cow-a! .cl n54(pie Or lOcculpa,,,, - 6Q Eakr S .swleplls Costa Mesa CA S2.576 TF--
TOME.
05/61/2996 13:90 619-5912165 HIGHLAND PARTNERSHIP PAGE 09/23 ç&/ZFIPIb i.:l b1Sb6
. RUL HENDOA . PAGE 01/93 ...................----7:'-,
416yes
.
SOUTH COAST MEDICAL CLINIC 4W. W StREET NAtIONAL CrFY.CA OM TEL '0446G,FAX19474*325
Assmg WVAM UEDWALcLApANcE RPOR
t!4PLOVEE mm ke—yga te 2
FF1YSTcL4ZY's OPJMONOFEMPLOYEE 174M7ls'A77ION
I. WAS TRI EMPLOYEE WAS DN EXAMINED ACCORDING TO ALL OF THE RQ1JIREMZ2lTS SET 1'ORTR IN 29 CPR I90.1001, 29 CFR 19I0.I34 AND CAC 5209? NO()
2. CAN THE EMPLOY SAPEIX WEAR A NEGATW1' IPRMURE RESPIRATOR' vIrLL THE EMPLOYEE BE AJILE TO PERPOR1%( mSfuER .TOB NOMAU.Y WHILE WEAR1FG A AlIVE PRSWB RESPIRATOR?
4..}YESONO
'
3. DOES THE EMPLOYEE IYLVE Ai'V L1MUVAT1ONS ON ELE TASKS EZ /5HZ CAN PERFORM WWLE WEARING A RES?J1ATOR? )YES
(\?f 0 IF flS, SPECiFY LtMITATIONS!'
4 DOES THE EMWYET HAVE ANY MEDICAL CONDMON wcgwOjju PLACk TM EMPLOYEE AT TKOIX.Alp-ISIc or HEALIB JMPLt1RMET FROM EXPOSURE TO' ASBESTOS ()ES (M? LFYESEXPLAIN
-.•
S. BAVF YOU INORMEI) TM EMPLOYEE, AS BQIURED BY LAW, OF TRE P.€Sutts OF 1'RI ExAM1r4AflON AND OF ANY MEDICAL COwmONS THAT MAY RESVLT F1.CYM EXPOVBE TO ASBESTOS!
NO? Th'YES,
EXAIN
•_. . •- .-
_____
-----
6 HAVE T= FOLLOWING EXAMWATIW MEN PERFORMED AND USED TO EVALTMTE TILlS ELOYCS-PISENT MEDICAL CONDITION?
CHEST X.RAY!"flVES ()NO SPThO7 117
, 9 '!ES ()NO
I rft'@iCs !JTOATTJR.E _
DATE,
_________________
/J,% ALEXLBANMJ
- t'- L CENL4 CO4øj
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05/01/2006 13:00 619_5912165 HIGHLAND PARTNERSHIP
PAGE U9/2
UL MOZA CONSTRUCTION, INC
(6 P)
IkeSde. CA 2O 2
fox: (619) QO.S2 RESPIRATOR FITTEST REPORT
I Name: I,11b
I
Type bf Fit Test Used:
-. Negaiivi Positive Pressure Irr
i
t
a
n
t
Smoke Name of Test Operator
:
BAtit. !'4ENDOZA
Date of Test: e7147
- Expiration Date: ,,/3 c
RESPIRATOR BRAND
MODEL
SIZE PASS/FAIL #1 ]OITH T700 TC-21C-152/P100
3M L P/F #2
SML. . P/F I #3
SML P/F I - :SML Pr
Worke(
Test Operator
This record indicates that you have passed or fail
e
d
a
q
u
a
l
i
t
a
t
i
v
e
fit test as shown above for the
particular respirator(s) sho
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s
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.
This record must be kept
f
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a
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EPA ACCREDITED
N? 14140
AHERA.APPROVED
UCCUTRAIN
OCCUPATIONAL TRAIN ING INSTITUTE) INCA 7
BE IT KNOWN TO ALL THAT
Geràrdo C. Perez
HAS SUCCESSFt LLYOPLE1ED A EJAYCOURSEAND, AFTER PASSING
THE REQUIRED EXAMENATION, IS AWARDED This CERTIFICATE
ON
Juy7,2OO6
. FOR
ASBESTOS ABATEMENT
CONTRACTORS I SUPERVISORS -ANNUAL REFRESHER
COURSE DATES: 7. 2006 EXAM DATE; July 7, 2006
AACS-R - 3153-06 14 _ Nubia
- 'UTHORtZED SIGNATURE ACCREDITATION NO.
JUty 2007 . -
ij,44-
. -
EXAM ADMINISTRATOR
DOSK APPROVAL #CA-017-04
5 Cri,o Ad 1i:;.A
Oci rn e'LIk., - C *a4r . 5O Ekr .. Sc I31 Ctz tF. CA MGM, TEL Vf 4G.Y&4L
EXPIRATION DATE
Nubia
I
byeg - IC Y ----
I-, SOUTH COAST MEDICAL CLINIC
408W. 110 STREET NATIONAL CITY, CA 91950
- TELN 6194744666, FAXN 619474-0325
ASBESTOS WORKER MEDICAL CLEARANCE REPORT
I EMPLOYEE NAME_c Q- ia Yd) C2 PereZ EMPLOYEE'S SS.N (//-
HEIGHT: ' WEIGHT: 2 ~ L1 b- AGE: DATE OF
I EXAM: _-t-,_S_MALE :(4 FEMALE ()
I PHYSICIAN'S OPINION OF EMPLOYEE EXAMINATION
HAS THE EMPLOYEE HAS BEEN EXAMINED ACCORDING TO ALL OF THE
REQUIREMENTS SET FORTH IN 29 CFR 1910.1001, 29 CFR 1910.134, AND CAC 5208?
NO()
CAN THE EMPLOYEE SAFELY WEAR A NEGATIVE PRESSURE RESPIRATOR? WILL
THE EMPLOYEE BE ABLE TO PERFORM HIS/HER JOB NORMALLY WHILE WEARING A
\ NGAT1VE PRESSURE RESPIRATOR?
'JJYES()NO
DOES THE EMPLOYEE HAVE ANY LIMITATIONS ON HE TASKS RE /SHE CAN
PERFORM WHILE WEARING A RESPIRATOR? ()YES (\)1O IF YES, SPECIFY
LIMITATIONS:
DOES THE EMLOYE1 HAVE ANY MEDICAL CONDITION WHICH WOULD PLACE THE
EMPLOYEE AT INCREA D-RISK OF HEALTH IMPAIRMENT FROM EXPOSURE TO
ASBESTOS? ()YES (
IF YES, EXPLAIN
HAVE YOU INFORMED THE EMPLOYEE, AS REQUIRED BY LAW OF THE RESULTS OF
THE EXAMINATION AND OF ANY MEDICAL CONDITIONS THAT MAY RESULT FROM
bTT TO A ' Tft9 EXPOSURE
'61'ES ()NO? IF YES,
/ EXPLAIN
I .6. HAVE THE FOLLOWING EXAMINATION BEEN PERFORMED AND USED TO EVALUATE
THIS EMPLOYES ID RESENT MEDICAL CONDITION?
CHEST X-RAY7"flYES NO SPmOMETRY1 YES NO
I
PW/SICIANS SIGr4ATURE
/ ALEX K. HAN MD.
DATE ... LICENSE#: G024691
I
- WORKER RESPIRATOR TRAINING & ACKNOWLEDGEMENT
I /I
DATE:
1 EMPLOYEE NAME
.•
.1 ) /
I AVAILABLE RESPIRATORS TO CHOOSE FROM:
NORTH 7700 SERIES, HALF FACE RESIRATOR
I c M7200 DUAL CARTRIDGE HALF MASK RESPIRATOR
- :•. . 2
I
D OTHERS:_
ACCESSMENT OF COMFORT -
I .)SmONING OF MASK ON NOSE i
KROOM FOR EYE PROTECTION
dU4JV i-OR 'JJ
I
ci POSmONIN LS OF MASK ON FACE AND CHEECKS
RESPIRATOR FIT .
iHIN PROPERLY PLACED
-. g( STRAP TENSION
cY'FIT ACROSS NOSE BRIDGE
I
. DISTANCE FR9M NOSE TO CHIN
ar TENDENCY TO SUP
' SELF-OBSERVATION IN MIRROR
o/ CONVENTIONAL NEGA1IVE/POSI1IVE FIT-TEST
I TEST EXERCISES - QUA1JTAT1V FIT -TEST/IRRiTANT SMOKE
.REATHE NORMALLY
O'BREATHE DEEPLY
'TURN HEAl) SDETO SIDE
.NOD HEAD UP AND DOWN
1' TALK (RAIPIBOW PASSAGE)
Cc/JOGGING IN RACE
' BREATHE NORMAUX,
RESPIRATOR(S) CHOSEN ODcQ4- Ll Aaci-6
THIS CERTIFIES THAT (5•c.-o V 6 I2Z HAS BEEN MPDE AWARE OF
THE HAZARDS INVOLVED IN WORKING Will-I ASBESTOS AND HAS RECEIVED TRAINING IN.
AND UNDERSTANDS THE CARE I)JE PFITHE ABOVE RESPIRATORS.
EMPLOYEE SlGNlTlJRE
TRAINER SIGNITURE
Respirator Medical Clearance Evaluation Review Form
ExamDatè: •3 I Z/ / C'
Employee Name: /S Age:
Employer: &9Y- 5' C.Y -C 7—
I conducted:
JReview of OSHA Mandatory Respirator Evaluation Questionnaire (appendix C to Sec. 1910.134). ± Physical examination and pulmonary function test.
Based on the above evaluation, I recommend the following for this patient:
-)No limitations with regard to respirator use.
- Some restrictions in respirator use as noted below under restrictions.
No respirator USC allowed.
Will need special lenses fitted for respirator use (cannot wear corrective lenses with respirato).
May need to remove facial hair if it interferes with respirator fit or use (evaluate during fit testing),
- Needs to return to clinic for respirator physical and spirometry.
Restrictions
Note: This evaluation did not include fit testing or endurance testing under simulated working coliditions.
Physiciau Date
Please circle name physician who preformed evaluation:
Lawrence S. Pohl, MD,MPH Mark Krisburg, MD Dorian Reed, PA-C
E1 F-IM 0 LIM -1M OM IIH 11 0 EIE ON EIM 00
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Certificate of Training
DE This is to certify that [III EIIM Fred Fuentes
LII .ILIJ
has successfully completed 40 hours of formal traini
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[II tII AHERA Contractor Supervisor
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Flo as approved y the California Division of Occupation
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Envvonmen,al Protection Agency and approved by AHERJ1 under TSCA Title Ii LI
•. LII LI Presented by
FM FIN Design For Health Training Center
3574 Kettiier Blvd,
San Diego, CA 92101
Phone: (619) 291-1777 Fax: (619) 291-4318
om
IL. FIM
OF]By:
DOSH Approval #GA -011-05 010 Virginia L. Shefa, B.., "If NSc., cJA.Q.P
Certificate #0306CS15345 ID LI President
Course Date: 03113-17106
T4 -Exam D. 03117/U L1 L IS U!I all 11 JI b7: 03/27/07 Lj
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OSHA 40 Hour HAZWOPER
This is to certify that
on July 27, 2002
Alf rr u.nir
has successfully complct.ed the OSHA 40-HourHAZtVOPER Training. This course satisfies the ieqtlirements for generalized employee training
under 051-iA (1910.120) arid State of California Regulation 5192 Title 8
Rick Wilson, Instructor Pet •s, Instructor C.'uyamaca College . Cuyainaca College
Mrk Bipes, [flStfuoj
Cuvamaca College ian j! Bogue
SD/REBRAC Director
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Certificate of Ti'ti in ing
This is to certify that
Fred Fuentes
!sos successfully completed 24 Ito ars offorma! (raining entitled
A HERA Building Inspector
as approved by the California Division of Occupational Safely and Health and L_I•
as certified by the Enviroumeit/al Protection Agency and approved byAHERA tinder TSc'A Title Ii
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DOSHApprovalfiC401105cla
Certificate 110406B!1 5504 ME]
Course Date: 0412,f-26106
Exam Dale: 04/26/06 FI N
Presented by
LI Design For Health Training Center
3574 Ketmner Blvd.
San Diego, CA 92101
Phone: (619) 291-1777 Fax: '619) 291-4318
TItic is an a,usl ceri'dication. 11, rust be newed h ':04/2.7
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