HOSPITAL BK 1 LT 2A-1 - ZCP 7/16/2019Kodiak Island Borough
Community Development Department
710 Mill Bay Rd. Rm 205
Kodiak AK 99615
oa Ph. (907) 486 - 9363 Fax (907) 486 - 9396
http://www.kodiakak.us
I
Print Form Submit by Email
III IIIIIIIIIII
ILII III III
23656
Zoning Compliance Permit Permit No. CZ2020-003
Property Owner / Applicant:
Mailing Address:
Phone Number:
Other Contact email, etc.:
Legal Description:
Street Address:
Use & Size of Existing Structures:
Providence Clinic
The following information is to be supplied by the Applicant:
Kodiak Island Borough/Providence
710 Mill Bay Rd., Kodiak, AK
307-486-9363
Friend Cont. - Mike Haffeman, 486-3908
Subdv: Ka4wakSN Block: 1
1915 Rezanof L
Lot: 2A-1
Description of Proposed Action:
Rebuild exterior wall.
Site Plan to include: Lot boundaries and existing easements, existing buildings, proposed location of new construction, access points,
and vehicular parking areas.
Staff Compliance Review: Current Zoning: Public Use KIBC 17.130
Lot Area: 11.92 Lot Width: Not Applicable Bld'g Height:
Front Yard: Not Applicable Rear Yard: Not Applicable Side Yard:
Prk'g Plan Rvw? Not Applicable # of Req'd Spaces:
Staff Compliance Review Notes and Specific Plat / Subdivision Requirements:
PROP ID 23656
Not Applicable
Not Applicable
Subd Case No. Plat No. Bldg Permit No.
Does the project involve YES
an EPA defined facility?
*Commercial buildings, installations (military bases),
institutions (schools, hospitals) and residences with
more than four (4) dwelling units.
Driveway
Permit?
Septic Plan
Approval:
Fire
Marshall:
Proof of EPA notification provided (if required)? YES
*Required for all demolitions, for renovations disturbing at least 160 square
feet 260 linear feet, or 35 cubic feet of Regulated Asbestos Containing Material (RACM), and
for renovations that remove a load -supporting structural member.
No permit will be issued for such projects without proof of EPA notification
Applicant Certification: 1 hereby certify that 1 will comply with the provisions of the Kodiak Island Borough Code and that 1
have the authority to certify this as the property owner, or as a representative of the property owner. 1 agree to have identifiable
corner markers in place for verification of building setback (yard) requirements.
04�-kr-
Attachments? dale— List Other:
Date: Jul 10, 2019
Signature:
This permit is only for the proposed project as described by tbX_W1kaDL.1L&k" are any changes to the
proposed project, including its intended use, prior to or during its siting, construction, or operation, contact
this office immediately to determine if further review and approval of the revised project is necessary.
THIS FORM DOES NOT AUTHORIZE CONSTRUCTION WHEN A BUILDING PERMIT IS REQUIRED.
** EXPIRATION: Any zoning compliance permit issued is subject to the same expiration, suspension, and revocation provisions as a
building permit issued for the same construction permit.**
CDD Staff Certification
11
Date: Jul 10, 2019 CDD Staff:
Payment Verification Zoning Compliance Permit Fee Payable in Cashier's Office Room **04 - Main floor of Borough Building
After -the -Fact 2X the published amount
Not Applicable
❑
$0.00 ❑ $0.00
Less than 1.75 acres:
❑
$30.00 ❑ $60.00
1.76 to 5.00 acres:
❑
$60.00 ❑ $120.00
5.01 to 40.00 acres:
❑X
$90.00 j (� ❑ $180.00
40.01 acres or more:
❑
$120.00 ❑ $240.00
R A 1
JUL 10 7019
KODlAWLANU OUNUGh
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Post Project Report
Kodiak Providence Hospital Abatement
1915 E Rezanof Drive
Kodiak, AK 99615
Client/Contractor
Friend Contractors
1950 Mill Bay Road
Friend Contractors
Kodiak, AK 99615
Prepared by
Satori Group, Inc.
1310 East 66th Avenue, Suite 2
Anchorage, AK 99518
April 2019
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SATORI GROUP
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TABLE OF CONTENTS
I. Notification
ll. Daily Reports
Ill. Visual Inspection
IV. Worker Certificates
V. Daily Air Monitoring
VI. Clearance Air Monitoring
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 Phone 907.332.0456 Fax 907.332.0457 vexvegosatori.com
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SATORI
I. Notification
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 Phone 907.332.0456 Fax 907.332.O457 w:w4.gosatori.com
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SATORI GROUP
NOTIFICATION OF ASBESTOS ABATEMENT
The intent of this letter is notification of the job and participating workers per AAC 61.620b
To: Alaska Occupational Safety & Health
Date: 3/21/2019
ACM Abatement Location
1915 E Rezanof Dr
Kodiak, AK 99615
Projected Time Frame
Start Date: 3/28/2019
Workers to be involved
Satori Project Number: 40437
End Date: 3/31/2019
Last Name
First Name
Cert #
Expires
Caldwell
Alan
20020632
01/31/2020
Taei
Bahaa
20150014
10/08/2019
Guzman
Payano
20160593
06/20/2019
Mercedes
Yunior
20160492
01/31/2020
Caldwell
Blake
20180305
05/25/2019
Rodriquez
Gustavo
20050848
06/20/2019
Resto Miranda
Jose
20160592
01/31/2020
Munoz Nunez
Agripino
20180791
11/30/2019
Chadwell
Adam
20190136
02/15/2020
Please contact me if you have any questions or require additional information.
acaldwellCcD,gosatori.com
Thank you,
A /� 4v/
Alan Caldwell
Operations Manager
APPROVED
DOL ASBESTOS NOTIFICATION
DATE: 3/21/20 1 9
APPROVED BY:'—
STATE OF ALASKA— DOL/OSH
MAINTAIN AT WORKSITE
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 Phone 907.332.0456 Fax 907.332.0457 www.gosatori.com
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SATORI GROUP
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II. Daily Reports
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 , Phone 907.332.0456 , Fax 907.332.0457 1 www.gosatori.com
1310 E 66th Ave, Suite 2
Anchorage, AK 99518
info@gosatori.com
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SATORI GROUP
DAILY FIELD REPORT
Competent Person: Bahaa Taei
Project Name: Kodiak Providence Hospital Abatement
Project Location: Kodiak, AK
Date: 03/28/19
Project #: 40437
Daily Report #: 1
Asbestos L�, Lead LJ Other LJ
WORK AREA PREPARATION PROCEDURES
1. Applicable EPA/DOL notifications current & posted
2. OSHA Job Board complete and displayed
3. SSHP and job field binder on site
4. Applicable SDSs on site and available
5. Secure the area
6. Notify other building occupants
7. Post demarcation signage
8. Shut down the HVAC
9. Secure the electrical system
10. Clean and remove furniture and fixtures
11. Tape and seal windows, vents, and all critical openings
12. Seal stationary items
13. Cover the floor and walls with polyethylene
14. Establish decontamination unit(s)
15. Establish waste load out unit
16. Establish negative pressure in area (Class 1)
TIMELINE OF WORK ACTIVITIES PERFORMED TODAY:
1:30 PM Crew arrived onsite and held the daily safety meeting.
Phone: 907-332-0456
Fax: 907-332-0457
www.gosatori.com
Completed In Process N/A
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1:45 PM Crew finished the meeting. Crew started loading in their tools, supplies, equipment, and setting
up the containment barriers and the decon unit.
2:30 PM Crew finished setting up the job site. Crew and CP inspected their PPE for proper fit and
function before properly donning them. CP then inspected the containment barriers and the
decon unit before the crew entered the containment and started removing GWB/JC.
Engineering controls used during today's work were: HEPA vacuums, wet methods, and prompt
cleanup.
3:30 PM Crew finished removing the GWB/JC and started cleaning the entire job site.
5:00 PM Crew finished cleaning the job site. Crew loaded out their tools, equipment, and bagged debris.
Crew finished the job and left the job site.
Page 1 of 3
1310 E 66th Ave, Suite 2
Anchorage, AK 99518
info@gosatori.com
SATORIGRO IP
o
DAILY FIELD REPORT
Competent Person: Bahaa Taei
Project Name: Kodiak Providence Hospital Abatement
Project Location: Kodiak, AK
Date: 03/28/19
Project #: 40437
Daily Report #: 1
DAILY SITE INSPECTION
1. Barriers and enclosure inspected during shift per regulations
2. Negative Air System being monitored and working properly
3. Demarcation signs posted
4. Applicable EPA/DOL notices displayed properly
5. Daily air monitoring report from previous day posted
6. Work practices reviewed and discussed with crew
7. Safety meeting held
8. Decon unit being monitored and working properly
9. Have all workers sign regulated area sign in/out sheet
10. Protective equipment donned and inspected
11. Electrical system used — GFCI's
12. Work area clean of trash and debris
13. Beginning/end of shift — water on/off
14. Storage area — secured
15. Load out area — secured
16. First Aid supplies — available and stocked
1. TYPE OF ACM AND/OR LEAD REMOVED PER ORIGINAL CONTRACT
GWB/JC
Phone: 907-332-0456
Fax: 907-332-0457
www.gosatori.com
Completed In Process N/A
0
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2. QUANTITY OF ACM AND/OR LEAD REMOVED PER ORIGINAL CONTRACT SQ FT, E
F 50SF
3. LOCATION IN BUILDING OF REMOVAL (ROOM #, FLOOR #, HALLWAY, BATHROOM
IA 505 Treatment Room 1
4. LIST ENGINEERING CONTROLS IN PLACE FOR PROJECT:
HEPA vacuums, wet methods, and prompt cleanup
5. NEGATIVE AIR PRESSURE READINGS FOR DAY - LIST LOW TO HIGH, INCLUDE READOUT:
6. LIST TIMES WHEN CONTAINMENT INSPECTIONS PERFORMED:
7. LIST TIMES WORKER PPE INSPECTIONS PERFORMED UPON ENTERING REGULA
Page 2 of 3
1310 E 66th Ave, Suite 2
Anchorage, AK 99518
info@gosatori.com
co
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SATORI GROUP
Competent Person: Bahaa Taei
Project Name: Kodiak Providence Hospital Abatement
Project Location: Kodiak, AK
Date: 03/28/19
Project #: 40437
Daily Report #: 1
8. LIST TIMES WHEN DECONTAMINATION AREA INSPECTIONS PERFORMED:
Phone: 907-332-0456
Fax: 907-332-0457
www.gosatori.com
9. CP CONFIRMED REGULATED AREA SIGN IN SHEET FILLED OUT CORRECTLY AND ACCURATELY:
;rew signed the regulated area sign in sheet properly
10. CP CONFIRMED AIR MONITORING CONDUCTED IN ACCORDANCE WITH WORK PLAN:
Fatori conducted the air monitoring in accordance with our SoW
11. LIST TOTAL QUANTITY OF DEBRIS GENERATED (# OF BAGS /
12. ANY CHANGE OF CONDITION FROM SCOPE OF WORK IN ORIGINAL CONTRACT:
13. CHANGES, DIRECTIVES, AND/OR INSTRUCTIONS RECEIVED OR GIVEN:
14. LIST SITE VISITORS / MEETINGS ATTENDED:
15. CONTRACTOR'S VERIFICATION
The above report is complete and correct, and all material and equipment used and work performed during
this reporting period are in compliance with the contract plans and specifications except as noted above.
Project Supervisor
Date
Page 3 of 3
03/28/19
--A
SATORI GROUP
Daily Satety fV eetinp,
Competent Person: Bahaa Taei
Project Name: Kodiak Providence Hospital Abp
Project Location: Kodiak, AK
Proper PPE for the Job Site
Respirator Inspections
Ladder Safety
Electrical Hazards
Falling Hazards
Burn Hazards
Scaffold Safety
Slip:
Weather
Sharp Ot
Chemical Hazar
Overhe
Biologic
SSHP a►
Additional site safety haz
Date: 03/ 2S /2019
Project Number: 40437
pan :
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/Trips/Falls
Heat Stress Potential
Conditions
Cold Stress Potential
jects/Tools. --"
Hand Arm Vibration
Js & SDS's
Flying Particles
Id Hazards
Moving Equipment
al Hazards
Safe Use of Power Tools F-1
id Location
ards and concerns
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III. Visual Inspection
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 , Phone 907.332.0456 Fax 907.332.0457 1 wwi-gosatori.com
Satori Group, Inc.
1310 E. 66th Avenue, Suite 2
Anchorage, AK 99518
LOCATION:
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Visual Inspection
Business /
Residence: Providence Hospital
Address: 1915 E Rezanof Drive
City: Kodiak
Room(s)
or Units Involved:
State: AK Zip: 99615
Visual -�
Inspection Date: 03/ � �% /2019
Project Name: Kodiak Providence Hospital Abatement
Satori Project No.: 40437
Client: Friend Contractors
Phone: 907-332-0456
Fax: 907-332-0457
www.gosatori.com
In accordance with the procedures specified in Satori Group's Work Plan and this
contract, Satori Group hereby certifies that the asbestos containing material has
been thoroughly abated and a confirmation visual inspection performed. Asbestos
Containing Materials (ACM) were abated in accordance with applicable 40 CFR
(EPA) and 29 CFR (OSHA) regulations by certified Alaska asbestos abatement
workers prior to commencing demolition.
By:""-
Bahaa Taei
Competent Person, Satori Group, Inc.
11.4
8idVbfure by Client Representative
Signature by Client Representative
Print Name
Print Name
Date
Title
Title
IV.
Worker Certificates
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 1 Phone 907.332.0456 ; Fax 907.332.0457 1 www.gosatori.com
ALASKA DEPARTMENT OF LABOR
Certificate of Fitness
ASBESTOS ABATEMENT
Issued
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ALASKA DEPARTMENT OF LABOR
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Daily Air Monitoring
1310 East 66th Avenue, Suite 2 Anchorage, AK 99518 Phone 907.332.0456 Fax 907.332.0957 i mvw.gosatori.com
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Satori Group, Inc. (Satori Group )
1310 East 66th Ave., #2
Anchorage, AK 99518
Telephone: (907) 332-0456 Fax: (907) 332-0457
Daily Inspection Report
Report Date 3/28/2019
Satori Group Job No 40437
Project Name Kodiak Providence Hospital Abatement
Project Manager Alan Caldwell Client Friend Contractors LLC
Satori Group Inspector Bahaa Taei Client Contact Jerrol Friend
Morning Afternoon
Start 2:30 PM On -Site Manager Bahaa Taei
Inspector hours
Stop 4:30 PM 2:00 Client Project #
Contractor Information
Contractor Satori Group, Inc. Foreman Bahaa Taei
1310 E 66th Ave. #2 Contractor Phone 907-332-0456
Anchorage, Alaska 99518
Contractor Fax 907-332-0457
Scope of Work
Shift ❑ Mobilization ® Bulk Removal ❑ Final Visual ❑ Other (See below)
F=❑ Pre -Cleaning ® Detailing ❑ Clear. Inspection
❑ Setup ® Bag -out ❑ Tear Down / De -mob
Work Area 505 Treatment Room 1
Notable Occurrences
Description
Crew arrived onsite and set up the air monitoring equipment. A total of six air samples were taken from around the
job site. One air sample was taken from a worker's breathing zone, one excursion air sample, one air sample was
taken from inside the containment, one air sample was taken from the exit of the decon unit, and two field blanks.
All air monitoring equipment was tested and calibrated before and after use today.
Sample Summary
# Sample Collected: PCM 6 TEM PLM
LEAD AIR LEAD WIPE TCLP OTHER
® Passed - proceed ❑ Need repairs - proceed ❑ FAILED ❑ Other...
❑ Adequate - proceed ❑ Inadequate - need reinspection ❑ Retest
Recorded By
Contractor Signature
l�
Bahaa Taei / Cert# 20150014 Bahaa Taei 3/28/2019
As a company representative, I aknowledge and authorize
the above work and subcontractor hours
Satori Group, Inc. (Satori Group )
1310 East 66th Ave., #2
Anchorage, AK 99518
Telephone: (907) 332-0456 Fax: (907) 332-0457
Project Name Kodiak Providence Hospital Abatement
Client Name Friend Contractors LLC
Sampled By Bahaa Taei
Analyzed By Alex Homer
Review
Comments
AIR MONITORING DATA SHEET
FOR ASBESTOS
7400 Method
Page 1 Client
Project
Number
Project # 40437
Sampled Date 4/1/2019
Date Analyzed 4/1/2019
Sample ID
0328-001
Location Breathing Sample inside breathing zone
TWA =0.047 f/cc
Sample Type
B
Work Removal of GWB/JC
temp. am/pm/avg. 70 / 70 / 70
Protection
H
Performed
temp. am/pm/avg. 70 / 70 / 70
Protection
H
- ---- - "
Worker Name Chadwell, Adam Cert # 20190136
SS#
Decon
DBS
Time Start 2:30 PM Flow Start 2
LOD 0.015 UCL 0.232
Environment
H
Liters /Fields f/cc
Stop 4:00 PM Stop 2
Fibers
Pump #
SGI 9
Minutes 120 included 1
Liters /Fields f/cc
Total No. of samples
Rotometer #
LV 1
Minutes 90 included 1
180.0 40/100 0.109
Sample ID
0328-002
Location Inside Controlled Area
0
Sample Type
I
Work Removal of GWB/JC
Performed
temp. am/pm/avg. 70 / 70 / 70
Protection
H
Pump #
SGI 3
Decon
DBS
- ---- - "
Time Start 2:30 PM Flow Start 2
LOD 0.011 UCL 0.192
Environment
H
Stop 4:30 PM Stop 2
Fibers
Pump #
SGI 14
Liters /Fields f/cc
Total No. of samples
Rotometer #
LV 1
Minutes 120 included 1
240.0 44/100 0.090
Sample ID
0328-003
Sample Type
0
Protection
H
Decon
DBS
Environment
H
Pump #
SGI 3
Rotometer #
LV 1
Sample ID
0328-004
Sample Type
STEL
Protection
H
Decon
DBS
Environment
H
Pump #
SGI 9
Rotometer #
LV 1
Location Outside Decon
Work Removal of GWB/JC
Performed temp. am/pm/avg. 70 / 70 / 70
Time Start 2:30 PM Flow Start 2 LOD 0.011 UCL 0.011
Stop 4:30 PM Stop 2 Fibers
Liters /Fields f/cc
Total 120 No. of samples
Minutes included 1 240.0 1/100 < 0.011
Location Excursion sample inside workers breathing zone
Work Removal of GWB/JC
Performed
Worker Name Chadwell, Adam Cert # 20190136
Time Start 4:00 PM Flow Start 2
Stop 4:30 PM Stop 2
Total No. of samples
Minutes 30 included 1
TWA =0.047 f/cc
temp. am/pm/avg. 70 / 70 / 70
SS#
LOD 0.045 UCL 0.905
Fibers
Liters /Fields f/cc
60.0 52/100 0.425
SAMPLES TYPES RESPIRATORY PROTECTION DECONTAMINATION ENVIRONMENTAL
STEL - Excision CL - Clearance PD - Pressure Demand, S - Supply Air DS - Decon w/Shower H - HEPA Vacuum
B - Breathing Zone XCL - Aggressive Clearanc CF - Continuos Flow, D - Decon w/o Shower N - Negative Pressure Enclosure
H - HEPA Exhaust PRE - Pre -Abatement BH - Blasting Hood, PAPR - Powered Air Pur DBS - Double Suit O - No Containment
I - Inside Work Area O - Outside Work Area F - Full Face Negative Pressure C - Controlled Area
N - Neg. Air Exhaust BL - Field Blank H - Half Face Negative Pressure
Page 2
Project # 40437
Sampled Date 4/1/2019
Client Project Number
Sample ID
0328-005
Location Field Blank
BL
Protection
ample Type
BL
Work Field Blank
nvironment
H
Pump#
Performed
temp. am/pm/avg. 70 / 70 / 70
Protection
H
Decon
DBS
Time Start
Flow Start
LOD 0.001 UCL 0.001
nvironment
H
Stop
Stop
Fibers
Pump #
Liters /Fields f/cc
Total
No. of samples
.otometer #
Minutes
included 1
0/100 0?000
Sample ID
0328-006
ample Type
BL
Protection
H
Decon
DBS
nvironment
H
Pump#
.otometer #
Location Field Blank
Work Field Blank
Performed temp. am/pm/avg.
Time Start Flow Start LOD 0.001 UCL 0.001
Stop Stop Fibers
Liters /Fields f/cc
Total No. of samples 1 1!100 0?000
Minutes included
Personal Air Samples
Date 3/28/2019
Project Name Kodiak Providence Hospital Abatement
Project Number 40437
Work Area Name A 505 Treatment Room 1
Worker/ Grouping ID Sample No.
Chadwell, Adam
Cert# 20190136
0328-001
0328-004
Satori Group, Inc. (Satori Group )
1310 East 66th Ave., #2
Anchorage, AK 99518
Telephone: (907) 332-0456 Fax: (907) 332-0457
Type Time(min) Result Units
8 hour TWA: 0.047
B 90 0.109 f/cc
STEL 30 0.425 f/cc
Sample Types: STEL - Excursion, B - Breathing zone Page 1
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SATORI GROUP
70
VI. Clearance Air Monitoring
1310 East 66th Avenue, Suite 2 Anchorage. AK 99518 . Phone 907.332.0456 , Fax 907.332.0457 1 www.gosatori.com
AK Environmental Consultants, Inc.
5700 Old Seward Highway, Suite 202
MECAnchorage, AK 99518
(907) 561-AKEC
Client: Satori Group
1310 East 66th Avenue #2
Anchorage, AK 99518
Client Project No: 40501
Project: Providence Hospital
PCM Air Sample Report
Report Date: 3/29/2019
Report No: 1453
Turnaround Time: RUSH
Collection Date: 3/28/2019
Collected By: CLIENT
Sample Count 4
Date Received 3/29/2019
Client #: Lab# Location Volume Density Fibers/CC
Liters (F/MM )
CL -07 A19-1970 CL - Inside Work Area 1200L < 7 < LOD
Client M
CL -08
Lab#
A19-1971
Location
CL- Inside Work Area
Volume
Liters
1200L
Density
(F/MM )
< 7
Fibers/CC
< LOD
Client M
Lab#
Location
Volume
Density
Fibers/CC
Liters
(F/MM )
FB -09
A19-1972
Field Blank
N/A
< 7
NA
Client M
Lab#
Location
Volume
Density
Fibers/CC
Liters
(F/MM )
FB -10
A19-1973
Field Blank
N/A
< 7
NA
Page 1 of 2
Analyst:
Approved By:
PCM Air Sample: Time Weighted Average
Date Analyzed: 31 �/201=
Date . 3 la b bi g
Analysis by NIOSH 7400 Method. Reporting Limit based upon 7 f/mm'. All results are based on the samples as received at the laboratory. AK
Environmental Consultants, Inc. (AKEC) assumes that appropriate sampling methods were used and the data upon which these results are based
has been accurately supplied by the client. Method requires the submittal of 2 to 10 field blanks per set. These results are corrected for
contamination by field or analytical blanks. Current annual Coefficient of Variation values will be updated as data becomes available. The Limit of
Detection (LOD) depends on sample volume and quantity of interfering dust and is <0.01 f/cc for atmospheres free of interferences. The method
gives an index of airborne fibers. It is primarily used for estimating asbestos concentrations, though PCM does not differentiate between asbestos
and other fibers. Use this method in conjunction with electron microscopy for assistance in identification of fibers. Fibers <0.25 µm diameter will
not be detected by this method. The Walton Beckett graticule area is 0.00785 f/mm' as verified by stage micrometer. Samples with
concentrations below the limit of detection are reported as <LOD. AVOID concentration means that the sample has been overloaded with
particulate matter and could not be reliably analyzed. Time Weighted Averages (TWA's) calculated based upon adjusted standard method (ASM)
for 8 hours. No certification or accreditation exists for calculating Time Weighted Averages. AKEC accepts no legal responsibility for the purpose
for which the client uses test results. This confidential report relates only to those item(s) tested and does not represent an endorsement by AIHA
or any agency of local or state governments nor any agency of the U.S. government. This report shall not be reproduced except in full, without
written approval of AKEC.
Page 2 of 2
AK Environmental Consultants, Inc.
5700 Old Seward Highway, Suite 202
Anchorage, AK
AEC (907) 561-253299518
61 2 3299518
Sample Chain of Custody
Client: 6A'•Ta p�n�s,�D Date: 3�Z`' j t4 Time:
Client Project: Client Project 4p.5-0)
Samples Relinquished By: Date: 7/24/t f 90'1— 3So-I l4k
Samples Received by: Date:
Samples Received by:
Sample Analysis Type: (write in column) P M PLM TEM LEAD TCLP Other (Specify)
Turnaround Time: (write in column) ush 1 Day 2 Day 3 Day 5 Day
Sample Number:
Collection Date:
Sample Condition:
Analysis Type:
Turnaround Time:
CL - 0-1
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It is the responsibility of the Customer to ensure that samples are correctly taken, labeled, and packaged. AKEC reserves the right to refuse
samples for analysis which are obviously unsuitable due to damage, incorrect or insufficient labeling, or incorrect sample loading. AKEC will
notify the Customer as soon as such a problem is identified and will discuss with the Customer the course of action to be taken.
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