3 PR Insp FBOP WOPM 10373 Planned Event FMO1 NYM WO Description: Asbestos Abatement Monthly Report Date Created: 7/7/2019 Asset #: Assigned to; FMO1-FMO1 Asset/Group Desc: Skill: 400 - Administratve Site Code: FPS Number: Building Code: - Serial NolVin: Model: If applicable, ensure all safety precautions are followed, to include, but not limited to "LOCKOUT/TAGOUT AND CONFINED SPACE ENTRY” PM Instructions and Material: Schedule: 33899 -Ereq Proc# NAP Instructions C7] ) 32300 Yes Asbestos Abatement Report - Monthly The following PE is to report ALL costs, quantities, and types of asbestos abatement to ensure proper reporting to DOJ. Review the steps below and submit the "Required Specific Documentation,” along with a copy of this PE as the cover page, in a .pdf file to the Regional Factities Administrator by the Ist of each month. The .pef file must be labeled in the following format - Segment, Month, and Year, For example, LEW0316. For reporting purposes, each abatement event (single purchase) rust be listed individually in a .pdf fle. Mf multiple abatement events take place in the reporting month, produce a “cover sheet” for each subsequent event to indicate the information as required below . Complete as requested, per each event. Js asbestos abatement in progress? slo asaanias A Description: L Sonor os een oe of, Funds? -— a. If B&F Project Number: 2. Was the asbestos in a previous 3. 1s the asbestos friable or non-friable? 4. Quantity abated (near feet, square feet, etc): 5. General description of asbestos abated (ie... pipe ins! 6. Is the asbestos being abated as part of an ESPC? REQUIRED SPECIFIC DOCUMENTATION: a If yes, report a& requested in #9 The .paf filo must include the following, Place a check mark in the space provided indicating the proper documentation is included: Order of BSF Monthly Report: Copy of the active or completed minor work order or WO>$10k. Include a brief description of the asbestos abatement in the Description field. . Copy of the BAF Monthly Report. Inctude a brie! description of the asbestos abatement in the Completion Comments fiekt. : Ensure the check box “Asbestos Abatement is required or has been completed” on the Complete Tab is checked, +) the asbestos abatement is procured on a Government Issued Purchase Card: a. Copy of completed and signed Credit Card Purchase Form, AND b. Copy of signed and dated Purchase Card Statement from JP Morgan Chase matching purchase, AND c. Capy of Invoice signed by the facilities manager certifying services have been received, 9, if the asbestos abaternent is procured on 3 Purchase Order or Contract: #. Copy of completed and signed Purchase Order or Contract, AND .. Copy of Inveice or Pay Application signed by facilities manager certifying services have been received, AND .c. Copy of Payment Voucher Validation Report 8¢ documents can be obtained from the Business Office and must contain appropriate signatures. 10. If the asbestos is abated during the course of an ESPC project, the ESCO (Envieonmental Services Contractor) shall provide a letier to the Facility Manager certifying that any specific asbestos abatement as identified on an application for payment or itemized schedule of values has been performed at the time of completion of that item of work. This letter shail include the cost of the abatement. The ESCO shall roport this information for every instance of asbestos abatement during the course of an ESPC project. The Facility manager shall send a signed copy of this letter to the Regional Facilities Administrator indicating concurrence with the dollar amount and notification of completion of abaternent. Note: “All abatement will be reported in the month it is identifiedlabated, if supporting documentation is not avaiable for submission to complete the evert during the initial reporting month then the event will be reported on each month until all required documentation has been finalized and submitted. “The Asbestos Monthly Report and all required documentation to complete each event is to be maintained on file in the Facility Managers office. Documents may be maintained electronically. “I no abatement was conducted, submit a copy of the completed PE stating no abatement was conducted during the month. Updated Aug 31, 2017 EFTA00142422

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3 PR Insp FBOP WOPM 10373 Planned Event FMO1 NYM Ensure all equipment has a MWI label affixed that is in clear view and legible. Ensure all MWI information is correct. LIST BELOW COMMENTS AND ALL MATERIAL USED. Act. Staff Hours: _ O 2 5 _ \ | i | No Alootement Ah s bux, Material Cost: : ws Date Completed: WS Staff Code | EFTA00142423