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 INSPECTION
FOR STATE USE ONLY
Building Assessed

Room/Functional Space

Date of Construction

Type of Material (Only ONE type may be check per individual page; see instructions)

Surfacing Thermal Miscellaneous	Material

Friable Non-Friable
Description

Square/Linear Footage

Percent of Area

Homogeneous ID No.

Damage Assessment
Type of Damage	YES	NO	Amount

(Square/Linear Feet)	Comments (Severity, Cause)
Deterioration
Delamination
Water
Physical
Other:
Extent of Damage

Localized Distributed	Is dust/debris present?

Yes No	Location

Was bulk/surface material obtained?

Yes No	If surfacing material, is dust/debris released when

material is brushed by hand using moderate pressure? Yes No
Accessibility (More than 1 possible answer; see instructions)

1 2 3	Comments

Is there a potential for disturbance of this material?

Yes No	Explain

Is this material in an air plenum or exposed to an air stream?

Yes No	Explain

Degree of Damage

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
Additional Comments

Signature(s) of Inspector(s)/Assessor(s)

ASB-4

MAR 13

B

ASB-4 Asbestos Management Plan, Room/Functional Space Inspection

Elaine White

2004-12-20

ewhite

NJDHSS