ASBESTOS SINGLE SAMPLING FORM
Design and Technical Services, Planning & Project Delivery
2-21 Materials Management Bldg., Edmonton, Canada T6G 2R3
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Sample Date
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(Room No.)
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Sample No.
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Sampled By
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Telephone
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Building:
Sample Location:
STEP 1 – SAMPLE TYPE (Select type of material then proceed to STEP 2 on page 2)
NOTE: ALL ASBESTOS SAMPLING MUST BE PERFORMED BY QUALIFIED PERSONNEL ONLY!
FLOORING
Vinyl Floor Tile (12” x 12”)
Sheet Vinyl Flooring
Construction Paper
Vinyl Floor Tile (9” x 9”)
Mastic/Glue
Paper Backing
Floor Tile (other)
Linoleum
Grout
Floor Levelling Compound (Cement-Like)
Floor Levelling Compound (Fibrous)
Other: specify
CEILING
T-Bar Ceiling Tile ( ’ x
Stipple Coat
Drywall Joint Compound
’)
Cement Ceiling Tile (
Plaster
Mastic/Glue
‘x
’)
Glue-on Ceiling Tile ( ’ x
’)
Spray-Applied Fibrous Insulation
Other: specify
Drywall
Cement Plaster
Drywall
Spray-Applied Fibrous Insulation
Mortar
Drywall Joint Compound
Wall Fill Insulation (Vermiculite)
Other: specify
Stipple Coat
Pipe Run Fibrous Insulation
Felt on Pipe/ Duct
Parging mud on Duct/ Pipe
Pipe Run Block Insulation
Mastic on Pipe/ Duct
Parging mud on Boiler/ tank
Gasket or Flange
Paper on Pipe/
Aircell Insulation
WALL
Plaster
Cement Board (Transite)
Grout
MECHANICAL
Pipe Fitting Insulation
Transite
Pipe/ Duct
Cast Iron Pipe Joint Packing
Other: specify
Duct
MISCELLANEOUS
Spray-Applied Fireproofing Insulation
Incandescent Light Fixture Backing
Elevator Brakes Shoe
Generator Exhaust manifold
Dust Wipe Sample
Debris (bulk)
Window Caulking
Fireproofing Overspray
Wire Insulation
Fire Damper
Firestopping
Duct Tape
Dust (bulk)
Asphalt
Plaster Overspray
Counter Top
Fire Curtain
Welding Blanket or Screen
Heat Resistant Glove
Oven Insulation
Other: specify
Concrete
Fume Hood Lining (Transite)
Diffuser Back Plaster
Refractory Insulation
Lab Equipment Insulation
Micro-Vacuum Dust Sample
Felt
Cement Board (Smooth)
Plaster
Black Tar
Patching Material
Other: specify
Roofing core (Define Layers)
Silver Paint
Window Caulking
Cement Board (Corrugated)
Brick/Block Mortar
Cement Plaster
Cement Board (Smooth)
Plaster
ROOFING
Asphalt Shingle
Cement Board (Corrugated)
Cement Plaster
BUILDING EXTERIOR
Wall Fill Insulation (Vermiculite)
Thermal Spray on Building Overhangs
Other: specify
Email: damien.fillier@ualberta.ca
Telephone: 780.248.1378 • Fax: 780.248.1855
Rev: March 2012
ASBESTOS SINGLE SAMPLING FORM
Design and Technical Services, Planning & Project Delivery
2-21 Materials Management Bldg., Edmonton, Canada T6G 2R3
STEP 2 – SAMPLE DETAILS (Please identify details of the collected sample)
SAMPLE DETAILS
SAMPLE LOCATION:
N
WITHIN GENERAL SPACE
S
E
W
CORNER
WITHIN CEILING SPACE
CENTRE
ABOVE SOLID CEILING
SIDE
WITHIN WALL CAVITY
ACCESSIBILITY:
HIGH ACTIVITY AREA
LOW ACTIVITY AREA OR BEYOND REACH OF AREA OCCUPANTS
CONDITION:
SEVERELY DAMAGED
MODERATE DAMAGE
GOOD
FRIABILITY:
EASILY BREAKS APART
MODERATE
NON-FRIABLE
COLOUR:
BEIGE
ORANGE
WHITE
LIGHT/
DARK
BLACK
PEACH
YELLOW
BLUE
PINK
Other: specify
GREY
DRYWALL
WHITE
BROWN
PURPLE
GREEN
RED
ENCLOSED
GREY
TAN
CEILING TILE BACKING/MATERIAL:
RED
FOIL
BROWN
FIBREGLASS
PATTERN (white streaks on floor tile): Click here to enter text.
COMMENTS:
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Send this completed form and the asbestos sample (sealed in a Ziploc bag) to:
Hazardous Materials Coordinator
Room 2-21 Materials Management Building,
University of Alberta, Edmonton, Alberta, T6G 2R3
Email: damien.fillier@ualberta.ca
Telephone: 780.248.1378 • Fax: 780.248.1855
Rev: March 2012