Asbestos Survey

Property

Property Address

Property Picture

Survey Date

Issued Time

Tenant Name Tenant Name

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Asbestos Management Survey Report

APPENDIX

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Technician

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Property Manager Property Manager

Agency Name

Agency Address

Agency Email

Agency Mobile

Agency Phone

Landlord

Landlord Name Landlord Name

Landlord Address

Email

Mobile

Phone

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For Technicians

Confirm

A safety appraisal has been conducted at this property.

All safety equipment as per safety induction training has been brought to the property.

Has this property been recently renovated?

Yes

No

Hazard Identification Report

Others

Comment

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Introduction and Site Information

Clients Name

Email

Mobile

Phone

Description of site and structure

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Date Landlord supplied Information

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Register of Asbestos Containing & Presumed Asbestos Containing Materials

Product Product

Level Level

Material Description Material Description

Sample Number Sample Number

Material Risk Material Risk

Priority Risk Priority Risk

Condition Condition

Location

Recommended Action Recommended Action

Section Buttons

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Register of Asbestos Containing & Presumed Asbestos Containing Materials (ACTION REQUIRED)

Product Product

Level Level

Material Description Material Description

Sample Number Sample Number

Material Risk Material Risk

Priority Risk Priority Risk

Condition Condition

Location

Section Buttons

Check if Action Required

Action Required

Potential for severe damage, however, does not currently appear to be friable or presenting an immediate serious threat to human health however this could easily become dangerously friable and unsafe over time with continued deterioration which would represent serious danger to human health in the future.
Damaged areas should be either encapsulated by an appropriately qualified Asbestos contractor and unsealed areas should be sealed with an Alkali resistant paint or removed by an appropriately qualified Asbestos contractor. When encapsulation, removal or sealing is undertaken, erect appropriate Asbestos danger signs and ensure tenants are notified in writing with copies of all correspondence recorded in the Asbestos Management Plan. Tenants must be instructed in writing to notify PCBU’s if accidental damage occurs. The PCBU that is notified must ensure all other stake holder PCBU’s with overlapping obligations are notified in writing and have confirmed receipt of such advice with copies entered into this management plan.
All correspondence regarding Asbestos remediation or disturbance should be recorded in this Asbestos Management Plan and regularly updated in perpetuity. Restrict access to this area whilst sealing, painting, repairing or removal work is undertaken and ensure any person entering the area is wearing appropriate PPE including a respirator with P3 filters whilst surfaces are being disturbed. Contact a licensed Asbestos removal company to assess and commence necessary action as soon as possible.
Remediation on these areas should be commenced within 3 months or another survey conducted to monitor deterioration. These areas must be re-inspected at least 6 monthly intervals until remediated.

Areas Not Accessible / Not Inspected

YES/NO

Check to select

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SURVEY RESULT

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Sheet 1

Material and Priority Algorithm Scoring Tool for Presumed Asbestos (Maximum Score)

Product type (or debris from product)

[1] Asbestos reinforced composites (plastics, resins, mastics, roofing felts, vinyl floor tiles, semi-rigid paints or decorative finishes, asbestos cement etc)

[2] Asbestos insulating board, mill boards, other low density insulation boards, asbestos textiles, gaskets, ropes and woven textiles, asbestos paper and felt

[3] Thermal insulation (eg pipe and boiler lagging), sprayed asbestos, loose asbestos, asbestos mattresses and packing

Extent of damage/deterioration

[0] Good condition: no visible damage

[1] Low damage: a few scratches or surface marks; broken edges on boards, tiles etc

[2] Medium damage: significant breakage of materials or several small areas where material has been damaged revealing loose asbestos fibres

[3] High damage or delamination of materials, sprays and thermal insulation. Visible asbestos debris

Surface type/treatment

[0] Composite materials containing asbestos: reinforced plastics, resins, vinyl tiles

[1] Enclosed sprays and lagging, asbestos insulating board (with exposed face painted or encapsulated), asbestos cement sheets etc

[2] Unsealed asbestos insulating board, or encapsulated lagging and sprays

[3] Unsealed laggings and sprayed asbestos

Asbestos type

[1] White (Chrysotile) only

[2] Brown (Amphibole asbestos excluding crocidolite) and mixtures (not blue)

[3] Blue (Crocidolite) and mixtures or type unknown

TOTAL MATERIAL ASSESSMENT SCORE (maximum score of 12)

Normal occupant activity

Main type of activity in area

[0] Rare disturbance activity (eg little used store room)

[1] Low disturbance activities (eg office type activity)

[2] Periodic disturbance (eg industrial or vehicular activity which may cause contact with ACMs)

[3] High levels of disturbance, (eg fire door with asbestos insulating board sheet in constant use)

Total

Likelihood of disturbance

Location

[0] Outdoors

[1] Large rooms, warehouse or well-ventilated areas

[2] Rooms up to 100 sq metres in area

[3] Restricted or confined areas

Accessibility

[0] Usually inaccessible or unlikely to be disturbed

[1] Occasionally likely to be disturbed

[2] Easily disturbed

[3] Routinely disturbed

Extent/amount

[0] Small amounts or single items (eg strings, gaskets)

[1] Less than 10 sq metres area, or 10 metre pipe run

[2] 10 to 50 sq metres area or 10 to 50 metres pipe run

[3] More than 50 sq metres, or 50 metres pipe run

Average of scores for location, accessibility and extent/amount (maximum score of 3)

Human exposure potential

Number of occupants

[0] None

[1] 1 to 3

[2] 4 to 10

[3] More than 10

Frequency of use of area

[0] Infrequent

[1] Monthly

[2] Weekly

[3] Daily

Average time area is in use

[0] Less than 1 hour

[1] 1 to less than 3 hours

[2] 3 to less than 6 hours

[3] More than 6 hours

Average of scores for number of occupants, frequency of use, and average time area is in use (maximum score of 3)

Maintenance activity

Type of maintenance activity

[0] Minor disturbance (eg possibility of contact when gaining access)

[1] Low disturbance (eg changing light bulbs in asbestos insulating board ceiling tiles)

[2] Medium disturbance (eg lifting one or two asbestos insulating board ceiling tiles to access a valve)

[3] High levels of disturbance (eg removing a number of asbestos insulating board ceiling tiles to replace a valve or for recabling, or leak repair)

Frequency of maintenance activity

Unlikely - almost never

Less than once a year

Less than once a month

More often than once a month

Average of scores for type of maintenance activity and frequency of maintenance activity (maximum score of 3)

TOTAL PRIORITY ASSESSMENT SCORE (this is the occupant activity score added together with the three average scores) (maximum score of 12)

Material assessment score

Priority assessment score

Total overall score(maximum overall score of 24)

Location Photo

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