DEPARTMENT: Design and Construction
PAGE: 1 of 2
EFFECTIVE DATE: January 12, 1999
POLICY DESCRIPTION: Environmental –
Asbestos Containing Material (ACM) Management
REPLACES POLICY DATED:
REFERENCE NUMBER: DC.005
SCOPE:
All Company facilities, including but not limited to, hospitals, ambulatory surgery centers, home
health agencies, physician practices, and all Corporate Departments, Groups and Divisions.
PURPOSE:
To require facilities to manage asbestos containing building materials (ACM) in compliance with
applicable Environmental Protection Agency (EPA) and Occupational Safety and Health
Administration (OSHA) regulations.
POLICY:
Facilities that identify materials containing asbestos must avoid disturbing and potentially exposing
ACM to any occupant. Facilities must prepare an Asbestos Operations and Maintenance Plan
(sample attached) and have it certified by an Industrial Hygienist or Professional Engineer. All plant
operation, building management, maintenance and custodial personnel and occupants in the
immediate work areas where ACM is located must read and abide by the Plan.
Facility personnel must take all necessary precautions to prevent asbestos fiber releases or resuspension of already released fibers, within the facility.
This policy addresses federal regulatory requirements. State laws or regulations may impose
additional requirements. Each facility should consult with Corporate Engineering Services and the
facility’s Operations Counsel to identify and comply with any such additional requirements.
PROCEDURE:
1.
Unless the area is under a planned abatement project, no employee or outside contractor may
disturb ACM. Disturb means any activity that will cause the material to be damaged or
become airborne.
2.
Anyone with evidence of any disturbance or damage of ACM must report it to the Facility
Manager or Director.
3.
Only maintenance workers properly trained and certified in accordance with the applicable
OSHA Standards may perform necessary preventive and emergency operations and
maintenance procedures other than visual inspection.
4.
A licensed asbestos abatement contractor must be retained by facility Administration to
perform operations and maintenance tasks in lieu of trained workers. The telephone number
of the contractor must be kept readily available by facility Administration and the Plant
Operations Department in the event that emergency clean up or repair is needed.
5.
Confirmatory asbestos testing must be performed prior to any renovation or demolition
activities in a building that was built prior to 1981.
DEPARTMENT: Design and Construction
PAGE: 2 of 2
EFFECTIVE DATE: January 12, 1999
POLICY DESCRIPTION: Environmental –
Asbestos Containing Material (ACM) Management
REPLACES POLICY DATED:
REFERENCE NUMBER: DC.005
6.
Only state-certified facility workers may perform “minor” abatement work related to smallscale, short duration repair duties in a facility. The facility must retain qualified outside
abatement contractors to perform asbestos abatement projects (non-maintenance) in
accordance with applicable state regulations. If the total amount of friable asbestos materials
in a facility being demolished exceeds 260 linear feet on pipes or exceeds 160 square feet on
other materials, the appropriate state agency should be notified prior to beginning the
abatement project.
7.
If a facility needs assistance in selecting an abatement contractor, it should contact the Corporate
Environmental Manager.
REFERENCES:
Occupational Safety and Health Administration (OSHA) 29 CFR 1910-1001
Asbestos Operations and Maintenance Plan (attached)
ASBESTOS OPERATIONS AND MAINTENANCE PLAN
Facility Name
Address
Plan Overview
Asbestos Management
Summary:
 Certain asbestos containing materials (ACMs) exist in a facility building. A set of drawings/ plans must
accompany this O&M Plan. A copy of the Preliminary Asbestos Survey report is available in the
facility’s Plant Operations Department.
 Any contractors and/or employees conducting repair, renovation, or construction work on campus that
have the potential to disturb ACMs (such as drilling, telephone cable installation, computer cable
routing, etc.) must obtain clearance from the Director of Plant Operations. The Director of Plant
Operation or Safety Director must advise the construction and maintenance contractors and Plant
Operation employees of the asbestos material, location and hazard; then have the contractor or
employee sign an acknowledgment of the disclosure.
 For any regulated asbestos abatement work, facility staff will retain “qualified” and state-certified
abatement contractors to conduct the work. If the facility needs assistance in selecting an abatement
contractor, it will contact the Corporate Environmental Manager.
 Wastes generated during an asbestos abatement project must be manifested and removed by the
abatement contractors. Waste manifests and project close-out documents must be kept in the Plant
Operations Department.
 Training manuals, training video tapes, and compliance records should be kept in the Plant Operations
Department.
Department/contact person responsible for asbestos Department:
management and maintaining the compliance file:
Contact Person:
Based on the preliminary survey conducted at the facility in ______(year), the following building materials
contain asbestos at this facility (Sample, please revise for your facility):
ACM Material
Location
spray-on fireproofing
throughout the buildings
pipe and insulation
boiler/mechanical rooms
building fire proofing
electrical room
pipe joint insulation
ground floor/above ceiling
transite board
boiler room and cooling tower
floor tiles and mastic
throughout the building
fire door core
various areas
The Asbestos Management Compliance File
Records
 A copy of this O&M Plan
 the most recent set of drawings showing the locations of ACMs
 all asbestos survey reports, including the preliminary survey and any
subsequent confirmatory sampling results
 all written notifications to agencies for asbestos abatement projects
 close out document package for each abatement project (It is acceptable
to archive, but never destroy, the abatement close-out documents)
Documents routinely
 all manifests, receipts, or equivalent documents
updated
 monthly or bi-monthly visual inspection (by facility personnel) logs
 personnel training records
Attachment to DC.005
ASBESTOS OPERATIONS AND MAINTENANCE PLAN
Facility Name
Address
Objectives:
 identify and document the location of any existing asbestos containing materials (ACMs)
 establish an Asbestos Operations and Maintenance Program to provide for routine inspection and
appropriate maintenance; and
 if necessary, arrange for the repair or abatement of ACMs.
This Operations and Maintenance Plan has been developed to manage presumed asbestos containing
materials and/or identified asbestos containing building materials (ACM) at Facility Name. The
materials listed in the summary sheet have been tested to contain more than 1% of asbestos by a
laboratory. To comply with Occupational Safety and Health Administration (OSHA) standards at 29
CFR 1910-1001, unless an area has received a homogeneous sampling and testing, we are required to
assume that the materials listed below may contain asbestos, and treat them as ACM. Although the
“asbestos manufacturing ban” occurred in 1977-1978, building materials containing asbestos in stock at
that time were used for construction until 1981. Unless tested negative, any material, especially
floor tiles or vinyl sheets, installed prior to 1981 should be treated as presumed ACM. The ACM
stated in this Plan is a collective term including both the confirmed and presumed asbestos
containing materials.
cement pipes
cement wallboard
cement siding
asphalt floor tile
vinyl floor tiles
vinyl sheet flooring
acoustical plaster
decorative plaster
textured paints/coating
adhesives/mastics
ceiling tiles/lay-in panels
spray-applied insulation
blown-in insulation
fireproofing materials
thermal taping compounds
high-temperature gaskets
laboratory hood/table tops
laboratory gloves
fire blanket
fire curtains
elevator brake shoes/panel
HVAC duct insulation
duct work flexible connects
boiler insulation
breaching insulation
transite cooling towers
pipe insulation
heating and electrical ducts
electrical panel partitions
chalkboard
roofing shingle
roof base flashing
thermal paper products
firedoors
caulking/putties
transite wall board
specking compounds
joint compound
packing (wall/floor penetrations)
vinyl wall coverings
The inhalation of asbestos fibers may cause serious health problems. Asbestos materials should not
represent a health hazard when left in place and undisturbed. To avoid the disturbance of ACM, all
plant operation, building management, maintenance, custodial, and occupants in the immediate work
areas where this material is located will read and abide by this Operations and Maintenance Plan. This
plan is intended to prevent asbestos fiber releases or re-suspension of already released fibers and to
control fiber releases quickly and safely if they do occur.

Unless the area is under a planned abatement project, no employee or outside contractor may
disturb ACM. Disturb means any activity that will cause the material to generate dust.

Anyone with evidence of any disturbance or damage will report it to the Facility Manager or
Director.

Only maintenance workers properly trained and certified in accordance with applicable OSHA
standards will perform necessary preventive and emergency operations and maintenance
procedures other than visual inspection.

A licensed asbestos abatement contractor will be retained by facility Administration to perform
operations and maintenance tasks in lieu of trained workers. This telephone number will be
kept readily available by facility Administration and Plant Operation Departments in case
Attachment to DC.005
emergency clean up or repair is needed. An emergency may be from a fire, flood, pipe break,
earthquake, hurricane, civil disorder or other causes.

Confirmatory asbestos testing will be performed prior to any renovation or demolition activities in
a building that was built prior to 1981.

Facility Name will employ a state-certified Plant Operation worker to perform “minor” abatement
work related to small-scale, short duration repair duties in the facility. The facility will retain
qualified abatement contractors to perform asbestos abatement projects in accordance with
applicable state regulations. If the total amount of friable asbestos materials being demolished
in the facility exceeds 260 linear feet on pipes or exceeds 160 square feet on other materials,
the facility will notify the appropriate state agency prior to beginning abatement. If the facility
needs assistance in selecting an abatement contractor, it will contact the Corporate
Environmental Manager.
Attachment to DC.005
ASBESTOS ABATEMENT MANAGEMENT
If an ACM must be removed as a result of a demolition of renovation project, or if the surface condition of
an ACM has deteriorated to the degree that asbestos exposure is possible, the facility will initiate an
asbestos abatement project.

For repair, “minor” asbestos abatement, or emergency response, the facility will get a local
asbestos abatement contractor licensed by the appropriate state agency to perform these small
projects. Minor abatement is defined as removal of asbestos material under 160 square feet or
260 feet of piping. If the quantities exceeded the limits, the abatement work is considered
“regulated.”

For a regulated abatement project, a local firm/contractor will conduct a confirmatory asbestos
testing in the area(s) to be repaired or renovated. A confirmatory testing report should include
the quantity of each type of ACM found in separate building areas. The facility will check the
firm’s or contractor’s state license and insurance before it contracts with them. If the facility
needs assistance in selecting an abatement contractor, it will contact the Corporate
Environmental Manager.

For those regulated abatement projects, the insurance requirements are listed in the following
table. The facility will require the consultant and contractor to provide a copy of an insurance
certificate with the project contract.
Form of Coverage
Limits
Worker’s Compensation
Employer’s Liability
Statutory
$1,000,000
Comprehensive General Liability (including Primary,
Excess, and Blanket Contractual Liability Insurance and $1,000,000
completed operations):
Combined single limit of not less than
Comprehensive Automobile Liability:
$1,000,000 per occurrence for all damages
Bodily Injury/Property Damage/Personal Injury
including coverage for owned, hired, and nonowned automobiles.
Professional Service Liability Insurance covering the $1,000,000 each occurrence
Work under each applicable Project Contract including $1,000,000 in the aggregate
Project Site Specific or Blanket Contractor’s Pollution
Legal Liability Coverage




Using the results/quantities of ACM obtained from the confirmatory testing and a set of plans
and specifications prepared by a qualified consultant, the facility will select an abatement
contractor through competitive bidding. The asbestos consultant may perform this bidding
process for the facility for a reasonable fee.
The contractor must file a notice with appropriate state and local agencies, and pay permitting
fees prior to beginning an abatement project. OSHA compliance monitoring for abatement
worker protection should be performed by the contractor.
During execution of an abatement project, the independent air sampling and site inspection
should be conducted by the consultant. Other construction or renovation work may start after
asbestos abatement is complete.
Waste derived from the asbestos abatement project must be removed, labeled, transported, and
disposed of properly by the contractor. Waste manifests must be signed by either the CEO,
Facility Manager or Director, or Safety Director at the facility as the “Owner Representative.” All
completed manifests should be returned to the facility in 45 days by the landfill operator. The
manifests, as part of the close-out documents, must be keep in the “Asbestos Compliance File”
in the Plant Operation Department.
Attachment to DC.005

A minimum of 10% of the project payment will be withheld from both the consultant and the
contractor until the close-out document has been received by the facility. After an abatement
project is complete, the facility will require the consultant/contractor to submit close-out
documents. This document package will be kept in the facility’s Plant Operations Department.
Upon receipt of the close-out documents, the facility may issue the final payment.
.
Attachment to DC.005
SAMPLE FORM: ACCESS TO NON-PUBLIC AREA REQUEST
Facility Name
[This form needs to be used when employees or contractors are about to enter areas where potential
exists for exposure to friable ACM.]
PLEASE READ BEFORE YOU SIGN IN
By signature below, I hereby certify that I am aware that the area I am entering contains asbestos
containing materials (ACM). I certify that I have been informed of the location and hazards of ACM; that I
have received training in the proper precautions to take when working around ACM; that I will comply with
proper work practices and that I possess, and have been taught about the use, wearing and disposal of
proper personal protective equipment.
Print Name
Signature
Affiliation
Date
Attachment to DC.005
SAMPLE FORM: PERSONNEL TRAINING RECORD
Facility Name
[The facility needs to keep track of the hazard communication and personnel training for those facility Plant
Operation or Housekeeping personnel who work around ACM. The need and frequency of training should
be determined jointly by the Risk Manager, Safety Director and Plant Operation Director, and a form such
as this should be used to track the training.]
Asbestos Management
ATTENDEE
SIGNATURE
Purpose of Training/Name of Trainer(s)
DATE
Attachment to DC.005
SAMPLE FORM: INSPECTION RECORD
Facility Name
[This form, or its equivalent, should be used to keep track of visual inspection of the surface condition of
ACM. A computerized preventive maintenance program may be used in lieu of this form.]
Asbestos Management
Inspection Items(e.g., ceiling Type of inspection #
Condition of ACM
tile in OR, etc.)
Good, Fair, Poor
(monthly, quarterly,
semiannual, emergency)
#
#
#
Inspected by Date
For sprayed-on fire proofing and ceiling tile: inspect these materials for damage or deterioration at
least every 3 months. Corrective action: initiate an abatement project by qualified contractor, or
have a qualified contractor encapsulate the material.
For floor tile and mastics, duct mastic, and roof materials: inspect these materials for damage or
deterioration at least every 6 months. Corrective actions include: repair or abatement project.
For general muffler insulation, pipe elbow insulation, pipe insulation, tank insulation, and valve
cover: inspect all insulation for damage or deterioration at least every 6 months. Corrective
actions include: glove bag removal or abatement project.
Attachment to DC.005
SAMPLE FORM: ASBESTOS ABATEMENT/MAINTENANCE RECORD
Facility Name
[This form, or its equivalent, should be used to keep track of any preventive or corrective
maintenance/repair/abatement work conducted. A computerized preventive maintenance program may be
used in lieu of this form.]
Asbestos Management
Location/Unit(e.g., boiler room, OR, etc.)
Maintenance/Improvement Item
Performed by DATE
(e.g., pipe insulation removal, etc.) (name of firm)
Attachment to DC.005