If the address on this form is different than the address of the building, submit a written explanation.
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1 ILLINOIS DEPARTMENT OF PUBLIC HEALTH AHERA THREE YEAR REINSPECTION ASBESTOS ABATEMENT PROGRAM SCHOOL INFORMATION FORM SECTION I NAME OF SCHOOL DISTRICT: SCHOOL ID NUMBER: SCHOOL NAME: ADDRESS OF SCHOOL: CITY: CHICAGO SCHOOL DIST Chicago, IL, DATE LAST THREE YEAR REINSPECTION WAS COMPLETED 3/12/2010 If the address on this form is different than the address of the building, submit a written explanation. SECTION II (Please type or print) PLEASE COMPLETE THE FOLLOWING FOR YOUR THREE YEAR REINSPECTION: DATE REINSPECTION COMPLETED: 4/26/2013 ENROLLMENT IDPH INSPECTOR LICENSE NUMBER: IDPH LICENSED INSPECTOR NAME (Please Print): Marcos Iwankiw IDPH MP LICENSE NUMBER: IDPH LICENSED MANAGEMENT PLANNER NAME (Please Print): Stephen Diblik DESIGNATED PERSON (Please Print): Ms. Lynn Crivello PHONE: 97 (773) /26/2013 Signature of Designated Person Date SECTION III PLEASE COMPLETE THE FOLLOWING INFORMATION FOR ANY CHANGES WITHIN THE SCHOOL DISTRICT. School building has been sold. Date of Sale: School has been closed. Date closed: School building has been demolished. Date: School building is asbestos free since last reinspection: Please explain in writing why the school building is now asbestos free and include the supporting documentation. If a new school building has been added to the district, submit either and exclusionary statement or a management plan and inspection report. Include the complete name, address and city of school building. Explain in writing if the address of the building is different than the address on this form: IL Revised 10.03
2 THREE YEAR REINSPECTION CHICAGO SCHOOL DIST 299 Chicago, IL, Unit: Building ID: IDPH ID Number: REPORT DATE: Friday, April 26, 2013 Prepared for: 125 S. Clark Street Chicago, IL Prepared by: 600 West Van Buren St., Ste 500 Phone (312) Fax (312) DO NOT REMOVE FROM SCHOOL REQUIRED BY FEDERAL LAW
3 April 3, 2013 Mr. R. Kent Cook Asbestos Program Illinois Department of Public Health 525 West Jefferson Street Springfield, Illinois Re: Three-Year Reinspections Dear Mr. Cook:, Managing Environmental Consultant (MEC), conducted the ThreeYear Reinspections and performed management plan updates for the (CPS) facilities in Region 3,4,5 Elementary Schools. Please update your records with the following information. School District: 299 Unit: Region: 03 School: IDPH ID: Building ID: Address: Chicago, IL, Building Contact: Contact Phone: Current Building Owners: Review Date: 4/26/2013 Inspector: Marcos Iwankiw Management Planner: Stephen Diblik Inspector IDPH License: Management Planner IDPH License: If you have any questions or comments, please contact us at (312) Sincerely, Stephen Diblik
4 Environmental tification to Occupants To: Faculty, Staff and Parents From: Date: April 03, 2013 RE:, Unit Chicago, IL, Dear Faculty, Staff and Parents, This letter is to notify you that the 2013 asbestos three year re-inspection has been completed at Herzl School CPC, following the Federal Asbestos Hazard Emergency Response Act (AHERA), 40 CFR Part 763, Subpart E and is available for your review at the main office of the school. Although asbestos-containing materials have been identified at, there is no reason to believe that any threat to the health of students or staff exists at this time. CPS will continue to carefully monitor the condition of asbestos-containing materials and if conditions warrant, all appropriate steps will be taken to maintain the health and safety of all building occupants. If you have any questions regarding this matter or require additional information, please feel free to contact Ms. Lynn Crivello, the designated Local Education Authority's Designated Person at (773)
5 Table of Contents I. School and Inspection Information II. Executive Summary III. Methodology IV. Abatement History V. Reassessments and Recommendations VI. Conclusions Table I: Inspector's Reinspection Findings Table II: Management Planner's Review APPENDICES: Appendix A: Assessment Sheets, Drawings and Photos Appendix B: Inspector and Management Planner Licenses Appendix C: Laboratory Accreditations Appendix D: Laboratory Results Appendix E: Chain of Custody Forms
6 SCHOOL AND INSPECTION INFORMATION 1. School Information School: Address: IDPH ID: Contact: 2. Unit: Chicago, IL, Building ID: Phone: Description of Facility Original Construction: Total Square Footage: Current Occupancy: Additional Construction: of Floors: LEA Designated Person Contact: Ms. Lynn Crivello Address: 125 South Clark Street, 17th Floor Chicago, IL Phone: (773) Managing Environmental Consultant MEC: Contact: Dan Juneau Address 600 West Van Buren St., Ste 500 Phone: (312) Fax: (312) Inspector Inspector Name: Marcos Iwankiw Signature: Date: 4/3/2013 Inspector IDPH license # Region: 03 Management Planner Management Planner Name: Stephen Diblik Management Planner IDPH license # Review Date: 4/26/ LEA Designated Person's Acknowledgement Signature: Date: 4/26/2013 The reinspection report and recommendations have been received by me and appropriate action will be taken by the School District. Signature: Date: 4/26/2013 Name: Ms. Lynn Crivello Unit : Building:
7 II. EXECUTIVE SUMMARY was retained by the (CPS) to perform a three-year asbestos reinspection of the. This inspection was conducted in accordance with the United States Environmental Protection Agency (USEPA) Asbestos Hazard Emergency Response Act (AHERA) part (b), and the ongoing Operations and Maintenance Program (O&M) originally designed in the School's Asbestos Management Plan. The purpose of this three-year reinspection is to record any condition changes in the asbestos-containing building material (ACBM) in the school since the previous three-year reinspection and the six-month periodic surveillance, to identify, assess, and include any Homogeneous Areas (HA) not identified in the Management Plan, and to recommend an appropriate response action to manage asbestos. The inspector conducted a three-year reinspection of this facility under Illinois Department of Public Health (IDPH) school reinspection requirements and AHERA, sections and The main building and each addition to the main building, if constructed at different dates, were inspected separately. Laboratory accreditations are included in Appendix C, laboratory results are included in Appendix D, and chain of custody forms are included in Appendix E. te: During previous inspections, some of the HA(s) were identified together as 9" x 9" floor tile (FT), mastics assoc. with 9" x 9" FT, 12" x 12" FT, mastics assoc. with 12" x 12" FT, pipe insulation, etc. Some of these HA(s) have been re-identified by areas that are uniform in color, texture, construction date, application date, and general appearance. The inspector has determined the following: A. The following HAs have changed assessment categories for Building : 4 Unit: 12"x12" VFT Light Beige w/dark Beige Spots Building:
8 B. The following new homogenous areas have been identified for Building : Unit: Building:
9 C. This reinspection covered only physically accessible and visible areas and materials that were identified in the LEA's management plan. The following materials were concealed and/or contained in areas that were inaccessible for sampling and have been classified as Assumed: x12 grey with white streaks floor tile 12x12 grey with white streak floor tile mastic Beige multi-colored carpet mastic 12"x12" VFT Light Beige w/dark Beige Spots 9"x9" Off White Floor Tile Mastic 12x12 VFT Light Beige w/dark Beige Spots Mastic Carpet Mastic The following areas were deemed to be inaccessible: x12 grey with white streak floor tile mastic 9"x9" Off White Floor Tile Mastic 12x12 VFT Light Beige w/dark Beige Spots Mastic Carpet Mastic Materials were also listed as "assumed" if they were in good condition and sampling was not conducted to avoid damage. This reinspection was conducted by Marcos Iwankiw, IDPH License # The Management Plan was updated by Stephen Diblik, IDPH License # Inspector and Management Planner Licenses are included in Appendix B. Unit: Building:
10 III. METHODOLOGY Tasks performed on-site included the following: IV. 1. Review current management plan, identify HA(s) and extract appropriate information. 2. Examine and verify abatement records. 3. Touch and visually and physically reinspect and reassess the condition of all friable known or assumed ACBM. 4. Touch and visually and physically reinspect all non-friable known or assumed ACBM to determine whether these materials have become friable since the last inspection or periodic surveillance. 5. Identify any condition changes that may affect Hazard Ranking of known ACBM or Assumed ACBM, as well as any HA(s) that have become friable since the last reinspection. 6. Collect bulk samples from each newly discovered friable HA or previously assumed and submit for laboratory analysis. 7. Tabulate reinspection findings and submit for management planner review and recommendations with appropriate response actions based on the AHERA Damage Category of the ACBM. 8. Submit reinspection findings and management planner recommendations to the LEA within thirty (30) days for inclusion into the management plan. ABATEMENT HISTORY The information collected from the existing management plan and inspection report(s) and from interviews with the school official revealed that the following asbestos abatement was conducted at the school since the previous Three year Reinspection. Abatement Dates: V. REASSESSMENTS AND RECOMMENDATIONS The reassessments and recommendations are summarized in Tables I and II on the following pages. Detailed Hazard Assessment Sheets and Drawings and Photos (if applicable) are included in Appendix A. VI. CONCLUSIONS The Building Three-Year reinspection has been completed and response actions have been recommended for both friable and non-friable materials. A timely execution of the response actions recommended will enable the LEA and the Designated Person(s) to effectively manage the existing ACBM. This three-year reinspection report should be inspected in the current Management plan at the CPS Central Office, and one (1) copy should be kept at the school for use when planning any renovation and/or demolition activities in areas where ACBM has been identified. Also, periodic surveillance documentation and any summary reports from any response actions that are executed at the school should be used to update the Management Plan. Unit: Building:
11 Table I Inspector's Reinspection Findings
12 School Unit Building ID Address Region 03 ASBESTOS REINSPECTION FINDINGS AND RECOMMENDATIONS Inspector's Reinspection Findings Table 1 Managing Environmental Consultant (MEC) 600 West Van Buren St., Ste 500 Phone: (312) Fax: (312) Inspector's Comments are Summarized at the End of the Report HA Material Description 'x4' Lay In Ceiling Panels 12x12 grey with white streaks floor tile 11 Material Quantity Material Units Material Location Asbestos Type Material Category Friable Damage Type Damage Quantity Damage Units Change in Assessment Category Damage Category ACBM with the potential for damage ACBM with the potential for damage ACBM with the potential for damage ACBM with the potential for damage MODERATE ACBM with the potential for damage ACBM with the potential for damage MODERATE ACBM with the potential for damage ACBM with the potential for damage MODERATE 3,500 Through-out School 4 classrooms (all) NO_ACBM ASSUMED MISC MISC N NONE 0 3,500 4 classrooms (all) ASSUMED MISC N NONE x12 grey with white streak floor tile mastic Beige multi-colored carpet mastic Hallways ASSUMED MISC N NONE 0 3 9"x9" Off White Floor Tile 1,000 CHR MISC N NONE "x12" VFT Light Beige w/dark Beige Spots 9"x9" Off White Floor Tile Mastic 192 Classrooms 1-4 (beneath 12"x12" floor tile) and parent room Milk Storage Room ASSUMED MISC N NONE 0 Yes 100 ASSUMED MISC N NONE ASSUMED MISC N NONE x12 VFT Light Beige w/dark Beige Spots Mastic Carpet Mastic Classrooms 1-4 (Benearth 12"x12" floor tile) and parent room Milk Storage Room 1,467 ASSUMED MISC N NONE B 4" Brown Vinyl Baseboard 4" Brown Vinyl Baseboard Adhesive Fittings on Fiberglass Pipe Insulation LF LF LF Parent room, staff room, office, Teacher's lounge Throughout School Throughout School Throughout School NO_ACBM NO_ACBM NO_ACBM MISC MISC TSI N N Y 5 6 Damage Reason Disturbance Potential MODERATE MODERATE MODERATE LOW MODERATE
13 School Unit Building ID Address Region 03 ASBESTOS REINSPECTION FINDINGS AND RECOMMENDATIONS Inspector's Reinspection Findings Table 1 Managing Environmental Consultant (MEC) 600 West Van Buren St., Ste 500 Phone: (312) Fax: (312) Inspector's Comments are Summarized at the End of the Report Reinspection Date 4/3/2013 Inspector Name Inspector's Comments Marcos Iwankiw /15/2013 Inspector's IDPH License Number / Expiration Date HA Number: B Inspector Comments:
14 Table II Management Planner's Review
15 School Address Unit Building ID Chicago, IL, Region 03 ASBESTOS REINSPECTION FINDINGS AND RECOMMENDATIONS Management Planner's Review Table II Managing Environmental Consultant (MEC) 600 West Van Buren St., Ste 500 Phone: (312) Fax: (312) Management Planner's Comments Summarized at the End of the Report HA Num Material Description Material Quantity Material Units 'x4' Lay In Ceiling Panels 12x12 grey with white streaks floor tile 12x12 grey with white streak floor tile mastic Beige multi-colored carpet mastic 9"x9" Off White Floor Tile 3,500 3,500 1, "x12" VFT Light Beige w/dark Beige Spots 9"x9" Off White Floor Tile Mastic x12 VFT Light Beige w/dark Beige Spots Mastic Carpet Mastic 192 1, B 4" Brown Vinyl Baseboard 4" Brown Vinyl Baseboard Adhesive Fittings on Fiberglass Pipe Insulation LF LF LF Material Location Asbestos Type Material Category Friable Damage Quantity Damage Units Damage Category Response Through-out School 4 classrooms (all) 4 classrooms (all) Hallways Classrooms 1-4 (beneath 12"x12" floor tile) and parent room Milk Storage Room Classrooms 1-4 (Benearth 12"x12" floor tile) and parent room Milk Storage Room Parent room, staff room, office, Teacher's lounge Throughout School Throughout School Throughout School ACBM Assumed Assumed Assumed Chrysotile MISC MISC MISC MISC MISC ACBM with the potential for damage 6 ACBM with the potential for damage 6 ACBM with the potential for damage 6 ACBM with the potential for damage Operations and Maintenance Operations and Maintenance Operations and Maintenance Operations and Maintenance Assumed Assumed MISC MISC ACBM with the potential for damage 6 ACBM with the potential for damage Operations and Maintenance Operations and Maintenance Assumed Assumed MISC MISC ACBM with the potential for damage 6 ACBM with the potential for damage Operations and Maintenance Operations and Maintenance ACBM ACBM ACBM MISC MISC TSI Yes LF LF LF
16 School Address Unit Building ID Chicago, IL, Region 03 ASBESTOS REINSPECTION FINDINGS AND RECOMMENDATIONS Management Planner's Review Table II Managing Environmental Consultant (MEC) 600 West Van Buren St., Ste 500 Phone: (312) Fax: (312) Management Planner's Comments Summarized at the End of the Report 4/26/2013 Review Date Manager Planner Name Stephen Diblik /15/2013 Manager IDPH License /Expiration HA Number B Management Comments
17 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 1 MATERIAL DESCRIPTION: 2'x4' Lay In Ceiling Panels HISTORICAL AHERA DAMAGE CATEGORY HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: ASBESTOS TYPE: ACBM FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be. DAMAGE REASON: DISTURBANCE POTENTIAL: MATERIAL LOCATION: Through-out School MATERIAL QUANTITY: MATERIAL UNITS: DAMAGE QUANTITY: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
18 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: HOMOGENEOUS AREA: 1 MATERIAL DESCRIPTION: 2'x4' Lay In Ceiling Panels MATERIAL LOCATION: Through-out School BUIDLING ID: MATERIAL QUANTITY: MATERIAL UNITS: DAMAGE QUANTITY: DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Comments: Management Planner's Signature: Date: 04/26/2013
19 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 10 MATERIAL DESCRIPTION: 12x12 grey with white streaks floor tile HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: 4 classrooms (all) MATERIAL QUANTITY: 3500 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
20 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 10 MATERIAL DESCRIPTION: 12x12 grey with white streaks floor tile MATERIAL LOCATION: 4 classrooms (all) MATERIAL QUANTITY: 3500 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
21 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 11 MATERIAL DESCRIPTION: 12x12 grey with white streak floor tile mastic HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: 4 classrooms (all) MATERIAL QUANTITY: 3500 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
22 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 11 MATERIAL DESCRIPTION: 12x12 grey with white streak floor tile mastic MATERIAL LOCATION: 4 classrooms (all) MATERIAL QUANTITY: 3500 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
23 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 12 MATERIAL DESCRIPTION: Beige multi-colored carpet mastic HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: Hallways MATERIAL QUANTITY: MATERIAL UNITS: DAMAGE QUANTITY: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
24 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: HOMOGENEOUS AREA: 12 MATERIAL DESCRIPTION: Beige multi-colored carpet mastic MATERIAL LOCATION: Hallways MATERIAL QUANTITY: DAMAGE QUANTITY: BUIDLING ID: MATERIAL UNITS: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
25 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 3 MATERIAL DESCRIPTION: 9"x9" Off White Floor Tile HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Chrysotile FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: Classrooms 1-4 (beneath 12"x12" floor tile) and parent room MATERIAL QUANTITY: 1000 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
26 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 3 MATERIAL DESCRIPTION: 9"x9" Off White Floor Tile MATERIAL LOCATION: Classrooms 1-4 (beneath 12"x12" floor tile) and parent room MATERIAL QUANTITY: 1000 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
27 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 4 MATERIAL DESCRIPTION: 12"x12" VFT Light Beige w/dark Beige Spots HISTORICAL AHERA DAMAGE CATEGORY 6 HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: Milk Storage Room MATERIAL QUANTITY: 192 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
28 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 4 MATERIAL DESCRIPTION: 12"x12" VFT Light Beige w/dark Beige Spots MATERIAL LOCATION: Milk Storage Room MATERIAL QUANTITY: 192 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Comments: Management Planner's Signature: Date: 04/26/2013
29 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 5 MATERIAL DESCRIPTION: 9"x9" Off White Floor Tile Mastic HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: LOW MATERIAL LOCATION: Classrooms 1-4 (Benearth 12"x12" floor tile) and parent room MATERIAL QUANTITY: 100 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
30 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 5 MATERIAL DESCRIPTION: 9"x9" Off White Floor Tile Mastic MATERIAL LOCATION: Classrooms 1-4 (Benearth 12"x12" floor tile) and parent room MATERIAL QUANTITY: 100 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
31 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 6 MATERIAL DESCRIPTION: 12x12 VFT Light Beige w/dark Beige Spots Mastic HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: Milk Storage Room MATERIAL QUANTITY: 192 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
32 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 6 MATERIAL DESCRIPTION: 12x12 VFT Light Beige w/dark Beige Spots Mastic MATERIAL LOCATION: Milk Storage Room MATERIAL QUANTITY: 192 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
33 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 7 MATERIAL DESCRIPTION: Carpet Mastic HISTORICAL AHERA DAMAGE CATEGORY 6 ACBM with the potential for damage HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: Operations and Maintenance ASBESTOS TYPE: Assumed FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be 6. ACBM with the potential for damage DAMAGE REASON: DISTURBANCE POTENTIAL: MODERATE MATERIAL LOCATION: Parent room, staff room, office, Teacher's lounge MATERIAL QUANTITY: 1467 DAMAGE QUANTITY: MATERIAL UNITS: DAMAGE UNITS: COMMENTS: Inspector's Signature: Date: 04/03/2013
34 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: BUIDLING ID: HOMOGENEOUS AREA: 7 MATERIAL DESCRIPTION: Carpet Mastic MATERIAL LOCATION: Parent room, staff room, office, Teacher's lounge MATERIAL QUANTITY: 1467 MATERIAL UNITS: DAMAGE QUANTITY: 0 DAMAGE UNITS: In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Operations and Maintenance Comments: Management Planner's Signature: Date: 04/26/2013
35 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 8 MATERIAL DESCRIPTION: 4" Brown Vinyl Baseboard HISTORICAL AHERA DAMAGE CATEGORY HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: ASBESTOS TYPE: ACBM FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be. DAMAGE REASON: DISTURBANCE POTENTIAL: MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 300 DAMAGE QUANTITY: MATERIAL UNITS: LF DAMAGE UNITS: LF COMMENTS: Inspector's Signature: Date: 04/03/2013
36 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: HOMOGENEOUS AREA: 8 MATERIAL DESCRIPTION: 4" Brown Vinyl Baseboard MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 300 DAMAGE QUANTITY: BUIDLING ID: MATERIAL UNITS: LF DAMAGE UNITS: LF In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Comments: Management Planner's Signature: Date: 04/26/2013
37 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: 9 MATERIAL DESCRIPTION: 4" Brown Vinyl Baseboard Adhesive HISTORICAL AHERA DAMAGE CATEGORY HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: ASBESTOS TYPE: ACBM FRIABLE: RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be. DAMAGE REASON: DISTURBANCE POTENTIAL: MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 300 DAMAGE QUANTITY: MATERIAL UNITS: LF DAMAGE UNITS: LF COMMENTS: Inspector's Signature: Date: 04/03/2013
38 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: HOMOGENEOUS AREA: 9 MATERIAL DESCRIPTION: 4" Brown Vinyl Baseboard Adhesive MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 300 DAMAGE QUANTITY: BUIDLING ID: MATERIAL UNITS: LF DAMAGE UNITS: LF In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Comments: Management Planner's Signature: Date: 04/26/2013
39 2013 AHERA REINSPECTION Inspector Assessment Form (REASSESSMENT) LEA NAME: UNIT NUMBER: BUIDLING ID: CITY/STATE: Chicago, Illinois AHERA INSPECTOR: Marcos Iwankiw SCHOOL NAME: INSPECTION DATE: 4/3/2013 ADDRESS: IDPH LICENSE NO: INFORMATION FROM PREVIOUS INSPECTION HOMOGENEOUS AREA: B MATERIAL DESCRIPTION: Fittings on Fiberglass Pipe Insulation HISTORICAL AHERA DAMAGE CATEGORY HISTORICAL DAMAGE REASON: HISTORICAL RESPONSE ACTION: ASBESTOS TYPE: ACBM FRIABLE: Yes RESULTS OF REINSPECTION AND REASSESSMENT This homogeneous area was reinspected and reassessed in accordance with Section and of AHERA and it's condition HAS NOT CHANGED when compared to the conditions of the last AHERA reinspection. The current AHERA DAMAGE CATEGORY is determined to be. DAMAGE REASON: DISTURBANCE POTENTIAL: MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 25 DAMAGE QUANTITY: MATERIAL UNITS: LF DAMAGE UNITS: LF COMMENTS: Inspector's Signature: Date: 04/03/2013
40 2013 AHERA REINSPECTION Management Planner Review Form LEA NAME: UNIT NUMBER: CITY/STATE: Chicago, Illinois MANAGEMENT PLANNER: Stephen Diblik SCHOOL NAME: REVIEW DATE: 4/26/2013 ADDRESS: IDPH LICENSE NO: HOMOGENEOUS AREA: B MATERIAL DESCRIPTION: Fittings on Fiberglass Pipe Insulation MATERIAL LOCATION: Throughout School MATERIAL QUANTITY: 25 DAMAGE QUANTITY: BUIDLING ID: MATERIAL UNITS: LF DAMAGE UNITS: LF In accordance with Sections and of the Asbestos Hazard Emergency Response Act (AHERA) the LEA must select a management planner to review the results of the inspection and assessment and recommend appropriate response actions. The original inspection of the above identified homogeneous area has been reviewed in accordance with Sections and with the following recommendations. The RESPONSE ACTION recommendation is: Comments: Management Planner's Signature: Date: 04/26/2013
41 2013 AHERA REINSPECTION
42 APPENDIX B Inspector and Management Planner Licenses
43
44
45
46
47
48 APPENDIX C Laboratory Accreditations
49 APPENDIX D Laboratory Results
50 APPENDIX E Chain of Custody Forms
51 Three-Year Reinspection Key to Terms CODE KEY ACBM Asbestos Containing Building Materials MISC SURF Miscellaneous Surfacing TSI Thermal System Insulation LF CF Linear Feet Square Feet Cubic Feet Loc Dist Localized Distributed MATERIAL MATERIAL CATEGORY MATERIAL UNITS DAMAGE TYPE
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