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ASBESTOS AND REGULATED WASTEINSPECTION REPORT

Parce1302E16610 53rd Street NortheastRogers, Minnesota 55374

Prepared For:District 3, MN/DOT

Prepared By:Industrial Hygiene Services Corporation

IHSC Project Number: M05-205

June 2006

1

CONTENTS:

Section 1 - Site Specifics and Certification

Section 2 - Summary of Actions Required For This MovelDemolition

Section 3 - Summary of all Asbestos and Regulated Wastes

Appendix I - Chain of Custody Forms and Analytical Results

Appendix II - Structure Location & Floor Plans

Appendix III - Licenses

2

SECTION 1Site Specifics and Certification

16610 53rd Street Northeast

SP: 8608-21TH: 101Parcel: 302ELocation: 16610 53rd Street Northeast, Rogers, Minnesota (see copies of site mapAppendix II)Number and type of Structure/s: One Residential with Attached GarageCurrent Owner: Mn/DOTExpected Disposition of the Structure: Demolition

Licensure: MDH certified asbestos inspectors (John Hastings, Eric Hjort, and TomSogard) conducted the inspection (Appendix III)

Certification: The undersigned certifies that this asbestos inspection was performed incompliance with MN Rules 4620.3460.

';)Signature: --=-=-~[t..!'..L~!t:"-4-~"'-'d.~'1LI-----;:---,--::-:-::-:c-c:--Amy J. Buckley, Ce

Date: ~(<t>f-"-F-Oh-

Certification: The undersigned certifies that this asbestos and regulated waste inspectionand report was performed under my direct supervision and I have reviewed its contentsand find it to meet or exceed Mn/DOT's contract requirements.

Signature: 4 A.~ ,Stephen A. dross: ertifiid Hazardous Materials Manager License # 1776

Date: b!B (tJ6

3

SECTION 216610 53'd Street Northeast

Summary of Actions Required For This Demolition

Asbestos Summary: The structure contained the following category I or II asbestoscontaining materials:

}> I each black sink undercoating located in kitchen 1 in good condition

The structure contained the following friable asbestos containing materials:}> 1 each light fixture heat shield located in hallway 1 in good condition}> 2 square feet gray linoleum located in hallway 2 in good condition

These materials are required to be removed for a demolition (See documents inSection 3 for the detailed sample locations, amounts, conditions and summary inventoryof all suspect materials).

Regulated Waste Summary:The following regulated waste found in the kitchen, living room, dining room, watercloset 1, bedroom 2, water closet 2, hallwayl, hallway 2, basement, pole barn and theslab.

Mercury:2 ft Fluorescent Bulb: I each4 ft Fluorescent Bulb: 5 eachThermostat: 1 eachSilent Switches: 27 each

PCBs:Ballasts: 9 each

CFC's:Refrigerator: 4 eachAir Conditioner (Window): 1 eachAir Conditioner (Central): 1 each

Treated Wood:CCA (green treat): 400 linear feet - Tongue & Groove Green Treat

20 linear feet - 6 x 6 Green Treated Posts100 linear feet - Landscape 6 x 6 Green Treated Posts16 square feet - Green Treated Pad

4

Regulated Waste:Lead Acid Battery: 4 eachTires: 112 eachPropane Tanks: 2 eachSmoke Alarm: 1 eachQuarts of oil: 3 eachGas Tanks: 2 eachGas Cans: 1 eachExhaust Fans: 2 eachClorox Bleach: 1 gallonGarage Door Opener: 1 each

White Goods:Stoves: 3 eachRange Hood: 2 eachDishwasher: 1 eachCeiling Fan: 1 eachDryer: 3 eachWasher: 1 eachWater Heater: 4 eachWater Pressure Tank: 2 eachWater Softener: 2 eachFurnace: 3 eachGrill: 1 each

Solid Waste:Trash: 12 1/4 YardsFurniture: 2 each

This waste is required to be removed before the demolition (See attached documentsin Section 3 for the detailed inventory of all regulated wastes)

Lead Based Paint:None

This waste is required to be stabilized before the demolition (See attached documentsin Section 3 for the detailed inventory of all regulated wastes)

5

SECTION 3Summary of all Asbestos and Regulated Wastes at

16610 53rd Street Northeast

MNffiOT Building Asbestos Inspection Form

One Form Per Structure

Company Perfonning the InspectionCompany's State Work Order NumberCompany's AddressCompany TelephoneInspector(s) Names

MNIDOT DistrictState Project NumberParcel NumberBuilding TypeAddress of StructureInspection Date

Industrial Hygiene Services CorporationMnIDOT Contract Number 885533585 Lexington Ave N, Suite 150, St. Paul, MN, 55126(651) 766-9811John Hastings, Eric Hjort, Tom Sogard

District 38608-21302EOne Residential with Attached Garage1661053'· Street Northeast, Rogers, MN 553744-19-06

Kitchen 1

Total I each

Friable

Black Sink

Undercoating

2%Chrysotile

1 each Good 8A Yes

Hallway 1Light Fixture 85%

1 each Good 9A YesHeat Shield Chrysotile

Hallway 2 Grey Linoleum21% 2 ft2

ChrysotileGood 21A Yes

Total Square Feet 2 sq ft, 1 each

6

DefinitionsSample Description

Condition

Quantity

Type of Homogeneous material i.e. sheetrock, siding,

ExcellentGood

Pooronly if contains> I% asbestos otherwise NA

• Standard Locations: Brl = Bedroom 1Br2~ Bedroom 2 (Etc)

.Kit = Kitchen

DR ~ Dining Room

WCI ~ Bathroom IWC2 = Bathroom 2

CI = Closet 1C2 = Closet 2 (Etc)

UR = Utility RoomFR ~ Family Room

0= Other (Name)

7

HI = Hall I

H2 = Hall 2 (Etc)SI ~Shed 1

S2 = Shed 2 (Etc)

D=DeckY=YardG = Garage

B = BasementEI = Entry 1E2 = Entry 2 (Etc)SW ~ Stairwell

MnlDOT Building Regulated Waste Inspection Form(One Form per Building)

Company Performing the InspectionCompany's State Work Order NmnberCompany's AddressCompany TelephoneInspector(s) Names

MnlDOT DistrictState Project NmnberParcel NumberBuilding TypeAddress of StructureInspection Date

Industrial Hygiene Services CorporationMnlDOT Contract Number 885533585 Lexington Ave N, Suite 150, St. Paul, MN, 55126(651) 766-9811Jolm Hastings, Eric Hjort, Tom Sogard

District 38608-21302EOne Residential with Attached Garage16610 53'd Street Northeast, Rogers, MN 553744-19-06

REGULATED WASTEIMATERIALS

Items Total Quantitv Locations;'siC, •••••••••••••••

•••••••• ·.. iii,i'·' , i< ................. , , ........" .. ,Heat Pumps None ---Air Conditioners 2 Kitchenl, ExteriorFire Extinguishers None ---Refrigerators 4 Exterior, Kitchenl, Kitchen2Freezers None ---Other None ---

in iiioii i· ......•. ,i.....·.. <;i .. ·.;<. .ii'··.·.·.··········...·. ..... ··············.<··i ····ii< .. <'Ballasts 9 Garage, Kitchen 2Transformers None ---Other None ---

.i'i«.<·.·.···· .i .. ·.··,.·,·« ·...·...···.···'<i...P«·ii .·.·.·.i···..·.·.·«< "·.iii·······<4 ft Fluorescent Bulbs 5 Garage, Kitchen 28 ft Fluorescent Bulbs None ---

HID Lamps None ---Thermostats I Hallway ISilent Switches 27 Kitchenl, Kitchen 2, Living

Room I, Living Room 2, FamilyRoom, West Entry, North Entry,

Hallway I, Hallway 2, WCI,WC2, BRI, BR2, BR3, BR4

Other (2 ft Fluorescent Bulbs) I .' Kitchen 21·;'..<1ii.·· , i .<i • .. c·,<··········· <.<

.' .......•......... • i.'· i ........

Lead Plwnbing None ---

Lead Paint . None ---Lead Paint Peeling (Sq Ft) None ---Other (Name) None ---

8

Items Total Quantity LocationsTreatedWolld .... ...

••••••••••...... i···· >

Creosote None ---

CCA (green treat) 400 linear feet-Tongue & Groove Exterior20 linear feet-6x6 Exterior

CCA (green treat) 100 linear feet-landscape 6x6 Exterior16 square feet - pad Exterior

Other (Name if Possible) None ---

l'Ia¢arlllluslReguillte\J ..... ••, .... ...

. ....Paint None ---Oil 3 quarts ExteriorGrease None ---Antifreeze None ---Fuels (Name if Possible) None ---

Lead Acid Batteries 4 GaragePesticideslHerbicides None ---Fertilizers None ---UnknownlUnlabeled Wastes None ---

Televisions None ---Radios None ---

Smoke Alarms I Hallway)Computers/Electronics None ---Refractory BrickIMold None ---Other (Tires) 112 ExteriorOther (Propane Tanks) 2 ExteriorOther (Gas Tanks) 2 ExteriorOther (Gas Can) ) ExteriorOther (Exhaust Fans) 2 WC), AtticlRoofOther (Clorox Bleach) ) gallon Kitchen2Other (Garage Door Opener) I Garage

'ii" ••••••••....... .·.'.i.'···.•>, ../. .. . ..... ,i

Furniture 2 WCI, ExteriorTrash (Estimate Yards) 12 Yo Yards Exterior, Living Room I, Garage,

WC2Stoves 3 Kitchen I, Kitchen 2, ExteriorDishwashers, etc. ) Kitchen IWater Heater 4 Utility Room, Exterior

Furnace 3 North Entry, Garage, UtilityRoom

Other (Water Pressure Tank) 2 Utility RoomOther (Water Softener) 2 ExteriorOther (Grill) I ExteriorOther (Range Hood) 2 Kitchen ), Kitchen 2Other (Ceiling Fan) ) Family RoomOther (Dryer) 3 Hallway 2, ExteriorOther (Washer) ) Exterior

••••••, >< •..•..

•••••••••, . • .> ,..

Septic System None ---

Flammable Waste Trap None ---Sediment Trap None ---Other (Name) None ---

9

Individual LocationsLocation Item Quantitv

Kitchen I Air Conditioner (window) IRefri!!erator I

Silent Switches 2Stoves I

Dishwasher IRange Hood I

Family Room I Silent Switches 2rp;l;no Fan I I

,

Living Room I I Silent Switch I 2I Trash I Y. vard

West Entry I Silent Switches I 2, ,

Hallway I Silent Switches 2Thermostat I

Smoke Alarm I,

Bedroom I ffiRll I Silent Switches I I,

Water Closetl (WCI) Silent Switches 3Furniture I

Exhaust Fan I, ' , , ,

~

,

Bedroom 2 ffiR21 I Silent Switches I 2, ,," , '

Attic/Roof I Exhaust Fan I I, , '

Garage Ballasts 64 ft Fluorescent Bulbs I

Lead Acid Battery 4Garage Door Opener I

Trash I vardFurnace I

, ' ',

" , ,

North Entry I Silent Switch 2Furnace I I

, , "

Kitchen 2 Refri!!erator IBallasts 3

4 ft Fluorescent Bulbs 4Silent Switches 3

2 ft Fluorescent Bulbs IClorox Bleach I !!allon

Stoves IRange Hood I

, ,

Living Room 2 I Silent Switches I I, ,

,', '

10

Individual Locations...... I •• .•.. ····.···.·Itelll< QllantitvWater Closet 2 (WC2) Silent Switches 2

Trash Y, yard..•...

•••••• . ••••••••••••••.

Bedroom 3 (BR3) I Silent Switches I• •

... ..Bedroom 4 (BR4) Silent Switches 1< ••••••• ... . .,

•••• . . > ••••••••••••

Utility Room Water Heater IFumace I

Water Pressure Tank 2

•••• •••••• •••••••••••••• ....... . ...•• > •.... ··.····0 ". ••

. ....

Hallway 2 Silent Switch ITrash Y, yardDryer I

" ..........••••••

..•• • . '" • .......... •

Exterior Tires 112Grill I

Furniture IPropane Tanks 2

Washer IWater Softener 2

Refrigerator 2Quarts or Oil 3

Gas Can IGas Tanks 2

Dryer 2Stove 1

Water Heater 3Air Conditioner (Central) I

Trash 10 yardsCCA (green treat) 400 linear reet - Tongue &

Groove20 linear reet - 6 x 6

100 linear reet - landscape 6 x 616 square reet - pad

, ....... '. .........> . ......... ............ ....• ,······0>.· ...... "> ........... . ..

11

Appendix I16610 53rd Street Northeast

Chain of Custody Forms aud Analytical Results

Building Name: PARCEL 302E, 16610 53RD STREET NORTHEAST, ROGERS, MINNESOTAMnJDOT PROJECT 8608-21, TH 101

IHSC Project No.: M05-205.1

Date: April 19, 2006mINDUSTRIAL

HYGIENESERVICESCORPORATION

Location I Material Identification PhysicaTiD I Quantity I Units T -Sample II I Results

Kitchen 1 Black Sink Undercoating Black 1 Each 8A 2% ChrysotileBlue Linoleum wi Yellow Adhesive 250 Square Feet 5BC None DetectedYellow Adhesive on Blue Linoleum 250 Square Feet 6BC None DetectedSheetrock Walls and Ceiling 550 Square Feet 3' None DetectedStove Pipe Liner Wall 1 Each 11A None DetectedPopcorn Textured Ceiling Material Ceiling 250 Square Feet 1A None Detected

Living Room 1 SheetrockPopcorn Textured Ceilina Material

Wall and CeilingCeiling

650250

Square FeetSquare Feet

3A1B

None DetectedNone Detected

IFamily Room 1 IBlown In Insulation Ceiling I 175 I Square Feet I 10A I None Detected IWest Entry Blue Linoleum wi Yellow Adhesive 75 Square Feet SA None Detected

Yellow Adhesive on Blue Linoleum 75 Square Feet 6A None DetectedPopcorn Textured Ceiling Material Ceiling 50 Square Feet l' None DetectedSheetrock Wall and Ceiling 400 Square Feet 3' None Detected

Hallway 1 Light Fixture Heat Shield 1 Each 9A 85% ChrysotilePopcorn Textured Ceiling Material Ceiling 100 Square Feet 1C None DetectedSheetrock Wall and Ceiling 400 Square Feet 3' None Detected

Water Closet 1 (WC1) Sheetrock Wall and Ceiling 200 Square Feet 3' None DetectedGreen Sheetrock Wall and Ceiling 200 Square Feet 4ABC None DetectedYellow Wallboard Adhesive Wall 40 Square Feet 7A None Detected

Bedroom 1 (BR1)

Bedroom 2 (BR2)

Gliller Textured Ceiling MaterialSheetrock

Gliller Textured Ceiling MaterialSheetrock - 2 lavers

CeilingWall and Ceiling

CeilingWall and Ceilin'

150550

200650



2AB3B

2C3C



!AlIic IBlown In Insulation Ceiling I 1000 I Square Feet I 10' I None Detected I

* = This result is inferred as consistent with an analyzed sample of the same material from another area.Page 1 of 2

MnlDOT TH 101 - Parcel 302E

I Location I Material Identification Physical 10 I Quantity I Units I Sample # I Results I

!Garage ISheetrock Wall I 200 I Square Feet I 1Q' I None Detected I

North Entry Popcorn Textured Ceiling Material Ceiling 150 Square Feet 12ABC None DetectedTan Floor Paper Paper 150 Square Feet 23A None Detected2 x 4 Rough CeilinQ Tile Ceiling 1 Each 14' None DetectedSheetrock Ceiling 450 Square Feet 1Q' None DetectedBlown In Insulation Ceiling 150 Sauare Feet 24' None Detected

Kitchen 2 2 x 4 Rough Ceiling Tile Ceiling 15 Each 14A None Detected2 x 4 Pinhole Ceiling Tile Ceiling 2 Each 15A None DetectedTan Linoleum wI tan adhesive 125 Square Feet HABC None DetectedTan Adhesive on tan linoleum 125 Square Feet 18ABC None DetectedSheetrock Walls and Ceiling 300 Square Feet 1QC None Detected

Living Room 2 12 x4 Rough Ceiling TileSheetrock

Water Closet 2 (WC2) /SheetrockGreen Sheetrock

CeilingWalis and Ceilin'

Walis and CeilingWalls and Ceiling

32450

15075

EachSquare Feet


14BC1QB

1Q'20ABC



Haliway 2 Sheetrock Walis and Ceiling 400 Square Feet 1Q' None Detected2 x 4 Rough Ceiling Tile Ceiling 4 Each 14' None DetectedLight Textured Ceiling Material Ceiling 125 Square Feet 13ABC None DetectedGrev Linoleum Floor 2 Square Feet 21A 21 % Chrvsotile

IBedroom 3 (BR3)~lSheetrock Walis and Ceiling =r m

425 I Square Feet I 1QA I None Detected I

Bedroom 4 (BR4) 2 x 4 Batwing Ceiling Tile Ceiling 21 Each 16ABC None DetectedSheetrock Walis and Ceiling 100 Square Feet 1Q' None DetectedWindow Caulk 1 Each 22A None Detected

IUtility Room IBlown In Insulation Ceiling I 2 I Square Feet I 24A I None Detected I

Exterior Roof ShingleRoof Tarpaper

15001500


25A26A


,. ;; This result is inferred as consistent with an analyzed sample of the same material from another area.Page 2 of 2

Mn/DOT TH 101 - Parcel 302E

ill CHAIN-Of-CUSTODY RECORD

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1/ ',':/7d,/// /_~/v

:J.()/J 1=s:1~ T-L I' I \ II II I I I /lbwr.s~ Wc.~?-b13 1;;,rl.U\ .~LncJ( T";.( I \ I ~ II I I I I I /

j;Jlffd

:J..f)C 1~~/r-c I \ I \ I \ I I I I I(9.-rA- I%:~t~~~:z I I I \ I \I I I I I I'J-M lo;~2JJ~Uu..lk I V I J I ~J I I II I

I:/f/Y;Jf;?kmfvjif)

Gener.ill Comments: Total Number 01 Containers

Relinquished by· Relinquished by:

Company·

Company: Company: Company:

Rec.eived by: Received by Relinquished by:

Company:~C Company:

0 ... .&Y/bd'/C:¥~ 10"e Date:~

ill CHAIN-OF-CUSTODY RECORD


IprOject Manager:~~ ITurn Request

Project Name: TJllo·f Normal: !X'-'-__~_

Samp'e< SIgnature" OJ. _ rJj~/")

IHSC Project No Noi-:'-7-D5"-1 Mrr:L.(3o')..G

Project Location / t,MO 5 3rc<,sl-I'J.E.

Ji/

Number

fFJ

Laboratory

Sample

7/J!)~i~

7J1!)

Received

Sample Condition

Comments

Sample Condilon as

Chilled YES J NO

Sealed YES I NO

en ~L:;a:;b;;.,;,;N;,:a:.:.m:.:.e:'::'- -1Qj LAB USE ONLYcB ~L:;a:.b;.;..p,;,r;,OJI,;"e;,:c;;,I,;,N;,;O;,;" ..., -l<: r -ro()

I

I

°l~g~ --III 0. U.c ~.!.

E u·",a:

"Z

I

v

~".--...;;

~

I

'S" .£ I Analysis Requested§:Q::i~"'~- 0:gS- "'"' .- .o.~ ~- 0. -" ~.;r~E•"'

13 Ix

V Iv

OatefTime Sampled

I

"if

t-/h%~

Other _

Rush: _

Page: (p of (~

/UO

/.",..-7"

, I

Samp-re ldcal::>n Description

~.;-w,'/Jfy~"-t.~,_ r;, r;,.<:M.t:.L.C""

/

1"-'"

1l1-sJ.ol-::; -6;Hl(7~ 11 Q&>','fV? />I

1..--: ..,f" I. r JJP~oE"Sh/~ U--

Sample 10

-;2i)!t

2c/A-

73ft-

7(P/1

"7/

"'\

/General Comments: Total Number of Containers

RelinqUished by: Relinquished by: Relinquished by:

Company: Company:

Received b Received by: Relinquished by:

Company:~,

Company: Company:

O"e dPJP-~ Date: Date:

LEAD IN PAINT RESULTSPARCEL302E

16610 S3,d STREET NORTHEAST

ROGERS, MINNESOTA

IHSC PROJECT NUMBER MOS-20S.1

Paint LeadMethod

Sample illDate

Sample DescriptionSample Concentration

Reporting

Collected Location Limit(mg/kg*) (mglkg*)

302E-Pbl 4-19-06Green Window Trim Exterior

Exterior <1000 1000North Side

302E-Pb2 4-19-06East Exterior Red Window

Exterior 100 450Trim

*mglkg milligrams of lead per kilogram of surface material, which is equivalent to part per million (ppm).

The Minnesota Pollution Control Agency's (MPCA) threshold for lead containing paint is 5,000 parts permillion (ppm).

The Occupational Safety and Health Administration (OSHA) has no minimum threshold of lead in paint,therefore, when working with paint that has detectable levels of lead, the provisions of the OSHA standard1929.62 would apply.

- 1 -

Interpoll Laboratories, Inc.4500 Ball Road NE

Circle Pines, MN 55014-1819Tel: 763-786-6020

Fax: 763-786'7854www.interpoll-Iabs.com

May 10,2006

IHSC3585 Lexington Av., N., Suite 150St. Paul, MN 55126

Attention: Amy Buckley

LABORATORY REPORT:IHSC PROJECT:

SAMPLES COLLECTED:SAMPLES RECEIVED:

#22911#M05-205.1 Parcel 302E

April 19, 2006May 2,2006

LaboratoryLog Number

SampleIdentification

MOLSample Type (mg/kgl

RL(mg/kgl

Total Leada

(mg/kgl QUAL

22911-01

22911-02

302E-Pb1, Green Window TrimExterior North Side Paint Chips 200 1000 < 1000

302E-Pb2, East ExteriorRed Window Trim Paint Chips 90 450 100

Method Blank 10 50 < 50

J

Respectfully submitted,

Gregg W. Holman, ManagerChemistry Department

GWH/cgMOL = method detection limitRL = reporting limitQUAL = qualifier< = less thanJ = a reported value which is equal to or greater than the method detection limit (MOL), but less than orequal to the reporting limit (RL).

aThe samples were analyzed by EPA Method SW-846, 6010B on 5/8/06.

All analyses were performed using EPA or other recognized methodologies.All units are on an "as received" basis unless otherwise indicated. MN #027-003-148

/\1'1 L:OUAL OPP()fTf!.Jl'-J!TY FfvlPLOYEj,~

() \

0'?--

3585 Lexington Avenue North'

ill Suite 150

CHAIN-OF-CUSTODY RECORD SI. Paul, MN 55126651-766-9811651-766-9822

IHSC Project No: fA ')t; -20~, I ~rCl.J)01.(. Page: / of (~ .

Analysis Requested Lab Name: J-yt-L n'.(/ / (; bS-~

..2.~

Project Manager: .1 f'hAI'.Jd.r; V~Q. '" LAB USE bNLY~

Turn Request =- ~. '"Project Name: / It Inr I

NormaL ~-", c:

,:o.~

'" Lab Project No,..:;. -'(3 ::=. c:-~Rush: ~ 0 Sample Conditon as-.

P,oj,c, local;on, )t,(,.(() S3r~AJ.# ,<:)tJ" , U

Other: .~ g - Received Laboratory- 0

)0 ~~. -

" a ~

~;; '" a.w Chilled YES / NO Sample0 ..c • •

Sampler Signature: / J.M",,- <"~ E Eu ,-u •

Sealed YES I NO Number•

N",,,,

~ "S,ample 10 ' , Sample(locatif'l Description DalefTime Sampled Z Sample Condition

" Comments

3fJU-fb l &,~ k/;~(P 70'\'...- c.;(/q!Oc. 6 X r a &'1. vI --j-vo' J Ilbdi.. S.'VL. I

;}o2£-fJh1-.~f 4xf-u;.lor Rut.. f.(ft'1 fat. 6 y: (/,JJ1;tk;'; r;,~ , - I,

,

, ,

,

>

G,nm'Co,;,'m,n" (~/1~LJ- Ar.J fj/A ~R(~" lA?/ r'"<::;,,JA I'd-... I. Total Number of Containers

R,lin,u;,h,d by/')M c"Jj;f:;-yJ ! R~linqJshed by: Relinquished by·

Comp.ny ~LLI:: C (/It:;/rII.. Company· Company:

Received by: \ t \ ..A- Rec.eived by Relinquished by

Comp.ny lII--.-\..----r. DO I I Company Company: .._.-

D... ~I 't-10b If- f3S Dale" Date:

Appendix II16610 53rd Street Northeast

Structure Location & Floor Plan

26,0'

~

MAIN FLOOR

38.0'

~BBRl

X1A X28

3CXBR2

X2C

26,O't 19A4B ~ClJ4 X4A ;7A lC

14.0' ~A LIVING ROOM 1

~A X18X10A

FAMILYROOM 1

PbHALLWAY 1

12.0'

WEST ENTRY

NO SCALE

NORTHENTRY

22.0'14,0' GARAGE

26.0'LEGEND:

1BX BULKSAMPLE lOCATION

o Pb1 LEAD PAINT SAMPLE LOCATION

24.0'

STATE PROJECT NUMBER: 8608,21TH 101

BUILDING MAlERIALS SURVEY

PARCEL NO: 302E16610 S3RD STREET NORTHEAST

ROGERS, MINNESOTAPROJECT NO:

MOS·20S,302 mINDUSTRIAL HYGIENEDRAWN BY, SERVICES CORPORATIONDH

'22~, BASEMENTXt9A L~~~A6

BR3 X'

@lA 3A~16BX~

20 X S<\ HALLWAY 120C • U20A cmc X24A38.0' 138 38,0'

Xt:C X17B/18B X'4CX14A

UViNGX15A

ROOM 2KITCHEN 2 X14B

X17CIl8C 19BX==4

'4,0'

17A/18A

Appendix III16610 53'd Street Northeast

LicensesMDH Inspectorls License/s

Copies of Analytical Laboratory Accreditationls

iWh!teSeartike,flANoi1Augusf31,2005. . .E)(aminatlonDate:!.A,UgtJst31;2Q05:· .

ia~ Stat~ En:ironm~ntal,Dd .l' 0 Box. 645, RiceLake,wi 54868

(800/254;98JI' . . .

>>>=-11. .Certijh;ateNo.:-5LM083T0501IR Expiration Date.: August31, '2006

.-' .,' " . '.. '. ,.' . -",'" ..,.. ",.".,' '. -'.' .. '."' .

..'.'. . .: :ThisJs to .certify that .:' :'

. . .. Amy BLJ¢k!ey.. . '. '.''ha~aitendedand successfullycompl?tedan .

' ·.yfSBESTOSTNSPEC'/'lJlt ".·:···REFRESllERTR.AiNlNGCOURSE·. '.

...... : :....... ··..permitt2dby < ....< ... the State ofMinnesOtaundetMi~~eSQtakules4620:3702to 46203722

'.:' ".........•.........•.... .....·..o,:;u:1 77Jeetsthe.~equireme~tsof· :' , .' '.'

•.•. ~'''(on-?O.of'''''lJ.Ofth'Tdx'''$"b,tO.n'.;Cdntrol A't(l'SCA) ., .·">0'~I7:~j

'))1(.'&4 ~.

, . . ... ..... ~ ~~ous MATERI.4l$ At ..1:. 0'- .. fAA fA\)"('" . . -VV"C

~.&~\~ . . .' t1,~~.'.'" . .'~~ . . . ~ .

~~~efGm~1Y_'__is designated as a

Certified Hazardous Materials Manager

v\.imuthfJ

~.. ''/;}'9!Il

. ----.- .... -~" .. --_.. ..' .. DArf ' ..

---. J11..__:.._ ..NO

9I~?!;~_~~~!~tmVED!' _TOR.

·.S/!. ;J>w(/l. ,•.l\I.

111(/l

~<3d.~ ;0<1>

Expiration Date, August 18. 2006

Z -C/:l:to,m mO(/)01~. .•.<1'.•....."".~\~....•:l<.A!.ili.~ ... >. .' .". i:~,- ,,,,cc; :~-i$ ,:.. ':,f}!: ;;:::1 dlfi~ ", .... ",:;;;0,,"

-;j{~~ ~~".~~,

."'"":.,. -~ ~.; Q-a 5" Z. »lA, i'o <"" Q):r :J ''''' G?I,tl',-" ..;;:. 1lI""'-'" - it> ItJ Y' .01'c'<' m"ili'.',~,!!!.~ -"'0ll,. . _ •.",- m m'~' &(-'o.'J OCb:< 8,',.,; ...i:i"," 0 0~. :;0'"

~

g ~t)!r~~~~

~~~J

~l

Traini.ng lnsfru{;:r.=

This is to certify thatEric L. Hjort

has attended an4 sticcessjillly completed an

ASBE8TOSLNSPECTORlfEFRESHERfil.;J.INING COURSE

flenfjitted bytkeState oflvJinnesota Ulule,.A1i1~~(jrota>Rules 4620.3702 to 4620.3722

. . and meetstlfefeq1liremems ofSection 206 ofTitIe II ofthe Tb¥icp'.Substances Cafltrol..4ct (TSCA)

con.du.t:ted by

Lake States Env.ironmental, Ltd."" m

White Bear Lake,iVJNon Augusf 18, 2i)05Examination Date: August 18,2005

Certificate No.' 5LM081805031R

1.4ke Siaies EJIvironmenlal, LtdP. 0 Box 645. Rice Lake, Wt54868(800) 254-9811

z ·~";::";;".II9 ~,::!~:g.;.;~: g~Q7. ~:[' :-

~ii.l.l:ii~~~...·~.ic:', :p('l'O,:~.'_-::-'(W' t1) ~.' .....,

r'i'f~il!£$~-.,J." ~ Q .~..""N ;:0 ,.;.;.

oer

'"

.[Examination Datfi.: MarQh3,2006

ThiSts to certify that

J6hri ?JJJ1 Ha$tings'has atten{Je4alqdsu,cceysfidlycompletffdan

. .' ASBESTOS INSPECTORINITIAL"'T'ElAININGCiJURSE

. ' ... ' ' ... ' . ..... ..·pennittedbY· '.' - .... '.' .... . 'theSta.te ofMinnesqta under MimJesota Rules 46203702 to 46203722 ..

. . ','. . . (l!idmeets thej-equire'mentso{ .' .' .. Secti9n206 ofTitle II ofthe 'toxi';~Ltbstaneesqonl;olAct (TSCA). .' . . conducted by . . .' .

..Lake·.Stiltes·.·El1it:irt1nmel1tal,.Ltd.. '.' tn-;-" " .

AlBA Bulk Asbestos Program - Individual Lab Results

.t!.QJn.e.

Page I of 1

Total Penalty POinlS 0p

Round Status PProgram Stalus

0) 4244

NONE (0)NONE (0)NONE (0)

OlHR ( 100)NONE (0)NONE ( 0)

0

Amerlun Indu.trlal HygIene Allol;latlonBuill. AlIb8llo8 Ana'vtlul TeelIng Plog/an"

Re.ults of Round A65-4051/1612.008

Susan M. GrtlbbfAmy J. BuckleyIndustrial Hygiene Services Corporation Laborotory 10 Number3565 Lel(lnglon Avenue Nolth 102840Suile 15051. Paul. MN 55126

lOI Designalion\Sample to Numbers A) 79:55 6)7322 C) 6877

Analysis Results from Laboratory Number 102840Asbestos (0A.) CHRY ( .) AMOS (3) TREM ( 2)

NONE ( 0) NONE (0) NONE ( 0)NONE (0) NONE (0) NONE (0)

Oltler Flbrous Malerials ('Yo) FBGL IRA FBOL (93) OTHR ( 2)NONE (0) NONE (0) NONE (01

NonfjbrotJs Malerial (%) MICA ( 75) QTHR ( ') MICA ( 53)Penalty Points Assessed 0 0 0

Analysis Resulls from Reference laboralory OileAsbesll),$ ("to) CHRy (7 ) AMOS (. ) TREM (' )

Olt'ler Fibrous Mateoah. ('!o) FBGl (80 )CELL (1)

Nonfjbrous MaiMer (0/0) MICA (45 ) QTHR (15 ) ACID (72 )ACiD (45 ) MlCA (25)

Analysis ResulLs tj(}m Reference Laboralory TwoAsbestos (%) CHRY (. ) AMOS (' ) TREM (2)

CHRY (TRA)Olher Fibrous Millerials ('Yo) FBGL (52 )

Nonllbrous Malenal (%) OTHR (96 ) OTHR (15) ACID (68 )MICA (30 )

Acceptable QuanlitaOQfl Range (%) CHRY [fRA-12) AMOS [fRA-8 ) TREM [fRA-3 )

OTHR

OTHR

(100)

(100 I

SummaI)' or Rasulls from all LabOratoriesType One AsbeslosType One MeanType Two Asbestos.Type Two MeallType ThfU AsbestosType Thrae Mean

Olher ASbestos TypesReporteQ In Sample

ACTN"'AclinolileAMOS=AmosileANTH;Anlhophyt~te

CHRY

"ACTN. AMOS. TREM

CHRY=ChrysoOleCRQC=CroddolileTREM-Tremolile

AMOS'.2

ACTN, ANTH, CHRY,

CELL"CeNulosoF8GL;Fiberglass/Mlneral WoolSYNT""Synlhclic

TREM3.•

ACTN, AMOS, ANTH.CHRY

ACIO" aciQ,sQluble traclion, ir.ctu"ing bul nollimiled 10. calctle,gypsum, QoIomile, magnesite, hydlomaQfleslte, anhyQrite, ilndoouanileMICA-Micaceous MaterialOTHR=Othar

Round Slalus; P-Pass

Program Stalus' P;PloliCieM

F;Fail TE '"' TempOlsrily Excused

NP-NonproflCiel'll NA =Not Applicable

MlcroanalVtlcal Science~ I Environmental and IndustrIal Sciences Oivhiilon I RTI Inlernatlonalj AIHA

httn·//nuhlic.rti.org/aiha/reoort indiv.cfm?R=A65-405&P=A65 1116/2006

03/28/2006 13:45 FAX 7637867854 Interpoll Laboratories~vv,

Environmental Labora/ory Certification ProgramScope ofCertification

THIS LISTING OF CERTIFIED FIELDS OF TESTING MUST BEACCOMPANIED BY CERTIFICATE NUMBER: 10314AA

Stat, Labontory ID: 027·00)·148 EPA Lab Cod" MN00059 Expiration Date: AprU 13.2006

INTERPOLL LADORATORIES, INC.4500 BaD Road N.E.Circle Pines, MN 55014Pbone 763-786-6020

Resource Conservation and Recovery Program

A.alyt. M.thod Mllltrix

~i, EPA 60108 Solid &lid Chemical Mlleri.h

"",,", EPA 6020 Noo-potAble Water

Arsenic EPA (iOleB Non-potable Wlttr

Alxttic EPA 6020 Solid &lid ehemiul Mtlcrilh

BullllJ\ EPA 6020 Solid IUld ClKmical Materillf

BlriWD fiPA 60108 Solid and Chemic., Materilll

Bariwn EPA 6020 Noo-poubll: Wiler

BlriwTl EPA 6010B Non-pola.blc Wllu

CNlmill/Tl EPA 6Ol0 Solid and Chemic.l M&lcrl-ah

Cadmium EPA 6010B NO'G1'Otlblc W.ler

CUtnium EPA 60108 Solid ltId Chcmiul Mtterll!J

Cadmium EPA 6020 Non.~blc Waler

Chromium EPA 6020 Solid I.lld Chemic..1M'\l~rials

Ctuvcni~ EPA 6010 Non.polable W.ler

Cbrorniwn. EPA 6010B ,Noft.palab!e W.ler

Cnrom,ilJlrI EPA 60108 Solid Vld Chemical MI\(rillli

Copper EPA 602.0 Solid U1d Chemical Mllenah

"-' EPA6010B Solid.,.(l Qlem,-cil Maltn.l,

COOP" EPA 6010 Non-potlblc. Wiler

C._ EPA 60108 f'lon·poUlblc WUCT

l<.o6 EPA 6020 Solid and Chemical M.lLrial~

l<.o6 EPA 6010B Solid ahd Chemical Mllerial~

l<.o6 EPA 6020 Non·potable Watu

Wd EPA 60108 Noo·potAble W,tCT

M=W)' BPA 6010 Solid. ead Chcmietl Millen'"

M=rt EPA 6020 Non·~le W.ler

Molybdenum EPA 6020 Solid WId Ctlcmic.' Mlllen.ls

Molybdenum EPA 60108 Non.poUlblc. W.ter

Page 11 ofl7 11J01/04 OZ7-00}-I<l'

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