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

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:	Check One:

Pipe Insulation	Air Cell

Elbow/Joint	Cementitious

Other:	Solid Lag

__________	Other: __________	SURFACING

Check One:	Check One:

Ceiling	Sprayed On

Wall	Trowelled On

Other:	Other:

__________	__________	MISCELLANEOUS

VAT

Ceiling Tiles

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:	Check One:

Pipe Insulation	Air Cell

Elbow/Joint	Cementitious

Other:	Solid Lag

__________	Other: __________	SURFACING

Check One:	Check One:

Ceiling	Sprayed On

Wall	Trowelled On

Other:	Other:

__________	__________	MISCELLANEOUS

VAT

Ceiling Tiles

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-6

MAR 13

D

ASB-6

Elaine White

2004-12-20

ewhite

NJDOH