Environment, Health and Safety

ASBESTOS MANAGEMENT REQUEST

Maintenance/Renovation/Demolition Planning

~PRIOR TO DISTURBING SUSPECT ASBESTOS CONTAINING MATERIALS~

DEPARTMENTAL ASBESTOS COORDINATOR INFORMATION
Coordinator Name:		E-mail:
Department:		Phone:

PROJECT INFORMATION
Building & Room number/area:

Specific location:

Project start date:

Planned project (Allow 10 days for survey results)

Emergency project (Emergency situation required)

Briefly describe work to be performed in the text box below. Include areas that may be impacted by utility connections, etc. If you have a floor plan, job specification or other attachment, please attach below as a text, Word or PDF file. The attached file size cannot exceed 4 MB.

Attach a file:

Type of Material		Quantity of Materials
	Floor tile and mastic	Estimated quantity:	Sq. Ft.
	Ceiling tile	Estimated quantity:	Sq. Ft.
	Pipe insulation	Estimated quantity:	Sq. Ft.
	Pipe joint/valve/fitting	Estimated quantity:	Sq. Ft.
	Tank insulation	Estimated quantity:	Sq. Ft.
	Trowel applied plaster	Estimated quantity:	Sq. Ft.
	Spray applied texture	Estimated quantity:	Sq. Ft.
	Gasket/gasket material	Estimated quantity:	Linear Ft.	Sq. Ft.
	Glazing	Estimated quantity:	Linear Ft.	Sq. Ft.
	Other:	Estimated quantity:	Linear Ft.	Sq. Ft.

Your name: (if different from the Coordinator Name above)

Please direct questions, concerns, or additional information pertaining to this Asbestos Management Request to laura.tomlin@wku.edu.

Clicking the "Send it in!" button below will e-mail a copy of this form to Laura Tomlin and will display a copy of the form that you can print for your records.

Last Modified 3/11/13

Environment, Health and Safety

ASBESTOS MANAGEMENT REQUEST

Maintenance/Renovation/Demolition Planning

~PRIOR TO DISTURBING SUSPECT ASBESTOS CONTAINING MATERIALS~

DEPARTMENTAL ASBESTOS COORDINATOR INFORMATION

PROJECT INFORMATION