New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

P. O. Box 369, Trenton, NJ 08625-0369

ASBESTOS MANAGEMENT PLAN - ROOM/FUNCTIONAL SPACE

BOILER ROOM RESPONSE ACTIONS
FOR STATE USE ONLY
Building Assessed

Room/Functional Space

SECTION I: TYPE OF ASBESTOS‑CONTAINING MATERIAL (CHECK ONLY ONE TYPE PER SHEET)
THERMAL

Check One:

Pipe Insulation

Elbows/Joints

Boiler

Duct

Breeching

Hot Water Tank

Other: __________

Check One:

Air Cell

Cementitious

Solid Lag

Asbestos Block

Other:

__________	SURFACING

Check One:

Ceiling

Wall

Other:

__________

Check One:

Sprayed On

Trowelled On

Other:

__________	MISCELLANEOUS

VAT

Transite

Other:

__________
Homogeneous ID No.

Check One

Sample Taken

Material Assumed	Material

Friable

Non-Friable	Total Sq./LF

Material

Localized

Distributed	Accessibility

(See Instructions)

1 2 3
Damage Assessment

Damaged or Significantly Damaged	ACBM With Potential for Damage

Thermal System Insulation	ACBM With Potential for Significant Damage

Damaged Friable Surfacing ACM	Any Remaining Friable ACBM

Significantly Damaged Friable Surfacing ACM	or Friable Suspected ACBM

Damaged or Significantly Damaged Friable Miscellaneous ACM
Response
Action(s)
Date of Response
Square/Linear Feet
Comments

SECTION II: TYPE OF ASBESTOS‑CONTAINING MATERIAL (CHECK ONLY ONE TYPE PER SHEET)
THERMAL

Check One:

Pipe Insulation

Elbows/Joints

Boiler

Duct

Breeching

Hot Water Tank

Other: __________

Check One:

Air Cell

Cementitious

Solid Lag

Asbestos Block

Other:

__________	SURFACING

Check One:

Ceiling

Wall

Other:

__________

Check One:

Sprayed On

Trowelled On

Other:

__________	MISCELLANEOUS

VAT

Transite

Other:

__________
Homogeneous ID No.

Check One

Sample Taken

Material Assumed	Material

Friable

Non-Friable	Total Sq./LF

Material

Localized

Distributed	Accessibility

(See Instructions)

1 2 3
Damage Assessment

Damaged or Significantly Damaged	ACBM With Potential for Damage

Thermal System Insulation	ACBM With Potential for Significant Damage

Damaged Friable Surfacing ACM	Any Remaining Friable ACBM

Significantly Damaged Friable Surfacing ACM	or Friable Suspected ACBM

Damaged or Significantly Damaged Friable Miscellaneous ACM
Response
Action(s)
Date of Response
Square/Linear Feet
Comments

ASB-7

MAR 13

E

ASB-7 New Jersey State Department of Health _______________________________

Elaine White

2004-12-20

ewhite

NJDHSS