EP 1110-1-30
31 Aug 01
FORM 5
PRE-DESIGN LEAD/ASBESTOS SURVEY
ASBESTOS DATA SUMMARY SHEET
1. Sample Number : _________________
2. Sample Location: _________________
3. Brief Description of Material Sampled: (See Table B-3)
a. Type of Asbestos ____________________________________________________
b.Percent Asbestos Content ______________________________________________
4. EPA NESHAP Friability Designation for Work Task
Friable _______ Non-Friable Category I ______
Non-Friable Category II ______
5.
Condition of ACM: Good _______ Fair _______ Poor _______
6.
Quantity: Meters _______________, Square Meters ___________________
7. Quantity: Linear Feet: _____________, Square Feet __________________
Figure B-5: Example Asbestos Data Summary Sheet
B-12
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