ASBESTOS INSPECTION FORM

FACILITY NAME:
ADDRESS:
CITY: Province
SITE CONTACT NAME: CONTACT PHONE:
OWNER NAME:
OWNER ADDRESS:
CITY: STATE:
OWNER CONTACT: OWNER PHONE:

FACILITY DESCRIPTION: G Agricultural G Commercial G Industrial G Institutional G Public G Residential

BUILDING DESCRIPTION (describe structure and size):_________________________________________________
_____________________________________________________________________ _
_____________________________________________________________________ _
NOTE: This Survey Form was designed to be used for ONE Building/Structure only. Use additional forms for additional structures.

PROFESSIONAL SERVICE FIRM:

ADDRESS:
CITY: Province
INSPECTOR’S NAME: PHONE NUMBER:
INSPECTION’S CERTIFICATION:
PM# -
TYPE OF INSPECTION: G RENOVATION G DEMOLITION DATE OF INSPECTION:

IS ASBESTOS CONTAINING MATERIAL PRESENT? G YES G NO See summary results on page 2.

Name____________________________________ Title:______________________________

Signature_________________________________ Date:______________________________

If ACM is present and will be disturbed, removed or abated:

)________________________________________
Phone #_______________________ Asbestos Abatement Contractor License #__________________

Region 3 on __________________ (insert date) _______________________

AQM-ASB-001 Rev. 4 Sep 2007 Page 1 of 2
 SUMMARY OF ABESTOS SURVEY/INSPECTION
Material/Product Surveyed1 Sampled? ACM Condition of Qty Friable?
– Yes/No2 Present ACM/ ACM – Yes/No
(%)3 Suspected ACM Present
(e.g. good, damaged) (lf, sf, cf)
ROOFING & SIDING
o Roof felt shingles  Yes  No  Yes  No
o Roofing shingles  Yes  No  Yes  No
o Roofing Tiles  Yes  No  Yes  No
o Siding shingles  Yes  No  Yes  No
o Clapboards  Yes  No  Yes  No
o Other– describe _______________  Yes  No  Yes  No
WALLS & CEILINGS
o Ceiling Tiles  Yes  No  Yes  No
o Ceiling Tile Mastic  Yes  No  Yes  No
o Sprayed/Troweled coating  Yes  No  Yes  No
o Asbestos-cement sheet  Yes  No  Yes  No
o Paneling, Tile, Baseboard Mastic  Yes  No  Yes  No
o Spackle/Joint compounds  Yes  No  Yes  No
o Textured paints  Yes  No  Yes  No
o Millboard, rollboard  Yes  No  Yes  No
o Vinyl wallpaper  Yes  No  Yes  No
o Insulation board  Yes  No  Yes  No
o Other– describe _______________  Yes  No  Yes  No
FLOORS
o Vinyl-asbestos tile  Yes  No  Yes  No
o Asphalt-asbestos tile  Yes  No  Yes  No
o Resilient sheet flooring  Yes  No  Yes  No
o Mastic adhesives  Yes  No  Yes  No
o Other– describe _______________  Yes  No  Yes  No
PIPES & BOILERS
o Cement pipe and fittings  Yes  No  Yes  No
o Block insulation  Yes  No  Yes  No
o Preformed pipe wrap  Yes  No  Yes  No
o Corrugated asbestos paper  Yes  No  Yes  No
o Paper tape  Yes  No  Yes  No
o Putty (mudding)  Yes  No  Yes  No
o Other– describe _______________  Yes  No  Yes  No
OTHER PRODUCTS
o Window Glazing Putty  Yes  No  Yes  No
o Building Caulk  Yes  No  Yes  No
o Gaskets/Packing  Yes  No  Yes  No
o Clothing/Cloth/Blankets  Yes  No  Yes  No
o Cement/mortar  Yes  No  Yes  No
o Metal-clad firebrick  Yes  No  Yes  No
o Gunnite/fire-proofing spray  Yes  No  Yes  No
o Hot-tops (ingot mold covers and  Yes  No  Yes  No
inserts)
o Other – describe _______________  Yes  No  Yes  No
1
This list is not an exclusive list of potential materials containing asbestos and the inspector should use it only as a minimal reference
of potential asbestos containing materials present.
2
No sampling is required if the inspector suspects that the materials are ACM and treats them as ACM. For a suspect material to be
classified as non-ACM, a minimum number of samples must be collected and analyzed as required by regulations.
3
All materials identified as having an asbestos content greater than 1% are considered to be regulated asbestos containing materials
(RACM).
AQM-ASB-001 Rev. 4 Sep 2007 Page 2 of 2