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DEMO-0141-2021 Office Use Ohly P erm it - 2QZ 1 DEMOLITION APPLICATION Permit Fee:.$ — Town ofQ-Umnsbury Invoice#: YZ�' 742 Bay Road,Queensbury,NY 12804 P:518-761-8256 www.gueensbury.net Flood Zone? Y N Reviewed By: 3 PocV, -awj"�S�L'Qq , n I - Demolition Location: Tax Map.ID#: **AN ASBESTOS .REPORT IS REQUIRED.WITH ALL DEMOLITION APPLICATION SUBMISSIONS** DEMOLITION INFORMATION: 1. Where will demolition material be disposed? -he,� r /q-v�✓� a►�S�t2 . 4CL 2. Type of structure to be demolished: a. Residence d.Storage Building❑ b. Garage❑ e.Other: `02 Cp.S C. Business❑ y 3. What type of utilities are connected to the structure: a. Gas❑ f.Well-Water Pump❑ b. Fuel Oil❑ g. Public Sewer❑ c. Propane:❑ h.other d. Electric❑ i. None e. Public Water❑ 4. Have ALL utilities(water,electric,etc.)been disconnected? Yes)( No ADDITIONAL INFQRN ION:: 1. Two inspections maybe required: .an inspection to determine that utilities are disconnected, if necessary, and a final inspection, after the structure is removed and the site is cleaned up and graded. 2. Twenty-four(24) hour notification is required for inspections. 3. Workers' Comp insurance information is required to be submitted with this application. Declaration:;)acknowledge that no structure(s)will be removed from the parcel until the demolition application has been reviewed and approved by the Town of Queensbury Building&Code Enforcement and Zoning Departments and a permit has been issued. I have read and agree to the above: PRINT NAME: SIGNATURE: DATE:- a�o2 Demolition Application Revised December 2020 n CONTACT INFORMATION: PLEASE PRINT LEGIBLY OR TYPE, PLEASE INCLUDE AN EMAIL � • Applicant Ot IVame(s)':--- ,olCll+��- ► L �- .. ,nQ, S Mailing.Address,_;C/S/Z: 1 h I(�;� ir.o Ci Q,c��. ftN C ' (^A Cell Phone: .Land Line: 5-06- 3(yS_ -igl9 Email: l6ks• eowL Moe..�Q,bt:�-bu;. I6-14. co&I • Primary-Owner(s): Name(s): Q.00:Ii-lau i,A , :(;(:Cr Ckv 'S Rlof,�e_ Mail ng.Adtl,ress,,C/5/Z:, .� 69 — -, Lr 10 cic- {Mecl- n;c-vi I(C- Cell Phone: Land.Qne: Email: C0.S, _. q �e WOE� c! e2J- e oiv. ❑Check if all work will be performed by property owner only. Contractor: (List all additional contractors on the back of this form) i Contact Name(s): C.Rondaf I �L -Cc, 4%ofj Contractor Trade: fLYCG}��.�1:'0•� 1 S, Mailing Address;C/S/Z: (q3 Wo2�cl•�u.c:tC N,�:ll I2 �-� C-le Cell Phone: Land Line: �)g, ei _. A:Co- i' (a �}s Email: **Workers' Comp documentation must be submitted with this application** Contact Person for any questions regarding this project: Cell Phone: Land Line: $"l� , -_ jq f,q Email: 0 Demolition Application Revised December 2020 - ``1 t iPc-i ietace is the Solution i 314 «oih Pearl 5�I eei 4 Albany,New York 12207 k, (518)434-4546�, Fax:(518)434-D891 CERT'�ICA.T F,OF A-SBES T DS T1Sr�AL EiSYER C IFIGI EuildinWAddress ('S I J eA r ���. C U��{'2 fJ e Specific Work Area Rc-,F a,,rcj CGS;!�K Abatement CompanyAa-r f 1 �y a u n m e°m 6� S� The asbestos work area,defined above,has been inspected by the TOYS Certified Project Monitor for completeness in accordance with the requirements of Industrial Code 56.This inspection-has been performed in general accordance with ASTM E1368.The Project Monitor's visual inspection was for visible visible asbestos-containing materials, dust and debris. By(Print Name) for -e 1 Date-3 Z, By(Signore) 7 J/3�, , Asbestos Cerd ication# G(e — C)9 4 c3 EST Z) Company Name Micwid aci� 1,62c., Er, EDV D MAR 2 6 2021 TOBUN DOF N U&CODEUSRY �Y Experience is the solutions 314\North Pearl Street v Albany,New York 12207 4 (518)43 4-=15 46 3 Fax:(513)434-0S91 March 30, 2021 E E3 D -� Mr. Chris Abele MAR Z02*I Abele Builders 14 Corporate Drive TOWN OF a;:?UEENSBURY Clifton Park,New York 12065 BUILDING COMES- Phone: (518) 365-4989 b W2-0 VIA E-MAIL: chris@abelebuilders.com RE: Visual Inspections—3 Polk Road, Queensbury,NY Adirondack Project No.: IH-21-357 Dear Mr. Abele: _ Adirondack Environmental Services, Inc. (Adirondack)was pleased to provide a Visual Inspection for the abatement of asbestos containing material on the roof and related chimney caulking at#3 Polk Road in Queensbury,NY. A survey conducted by Adirondack in November, 2020 indicated three materials,roofing tar paper, caulking between the exterior chimney and the wall of the residence had asbestos containing material(ACM) as well as a small amount of linoleum in the bathroom.Martin Environmental of Schenectady,NY,the abatement contractor, was contracted to abate the material. ` The abatement work was completed March 26, 2021. By prior agreement Adirondack mobilized to the site on the afternoon of March 26 to conduct a visual inspection of the abatement process. The inspection was considered satisfactory and the inspector signed the abatement supervisor's log book to that effect. Note: the small amount of linoleum had been removed previous to this inspection. The inspection was performed by George Bailey of Adirondack,NY State DOL Certification 906-09450. Due to delays by the DOL certification renewal has been completed,and will be effective through October, 2021,but identification"hard cards"have not been issued. The current certification—"half sheet" is included in the attachments. Additionally,Adirondack completed a Certificate of Asbestos Visual Inspection. Copies of those certificates are attached to this report. Attachment A includes the Certificate of Asbestos Visual Inspection. FILE COPY Attachment B includes personal certifications, including the current"halkege TOWN OF QUE 13 BUILDING & Reviewed By. Gate: Visual Inspection—3 Polk Road Adirondack Project No.IH-21-357 1 I P a g 0 f ' • i i [i Experience is the soiut ion 314 North Pearl Street 4 Albany.New York 12207 s (518)434-4546+Fax:(518)434-0891 Thank you for selecting Adirondack Environmental Services, Inc. for your asbestos management needs. If you have any questions or require further information,please feel free to contact me at (518)434-4546. Very truly yours, ADIRONDACK ENVIRONMENTAL SERVICES,INC. Digitally signed by: F -1 George Bailey Date: 2021 .03.30 ' 12:13:13 -04'00' George Bailey Asbestos Project Manager—Industrial Hygiene and Safety Services Attachments Visual Inspection—3 Polk Road Adirondack Project No.IH-21-357 2 P a g 0 d ; 0 Experience is the solution 314 North Fear!Street 0 Albany, New York 12207 0 (518)434-4546 o- Fax:(518)434-0891 Attachment A VISUAL INSPECTION CERTIFICATE P I , Wp RPM �PJ Experience is the solutio," 314 Narh Pearl Street 6 Albany,New Yorlc 12207 4,-(518)434-4546 4s Fax;(518)434-0891 b f g r� �f CERTMCA.TE OF ASBESTOS WISIML DgSPECTIO•N !� Building/Ad&ess S 1 d clrl ae- ava:p-ns Specific Work Area Re C'himinal CC i J II jl I fir , IF Pr Abatement Company�y f i/J GYl yl ft)n M el.6( SIerV i e- 5. Irl G• r The asbestos work are defined above has been inspected b the liYS Certified Project � � P Y � _ Monitor for completeness in accordance with the requirements of Industrial Code 56.This f inspection-has been performed in general accordance with ASTM E1368.The Project Monitor's visual inspection was for visible visible asbestos-containing materials,dust and f } debris. By(Print Name) C,e or -e Bou ! Date E`r= By(Signature) 13 .:.; }-rt: Asbestos Certification# 6 6 — o q 4 6 Exp 16 L2!�21 €`' Company Name 1 lrondacV f5�.'NvirQnm .ntml 5:aryic.eS. lnc, U. Y yy%. [�9 0 Experience is the solution 314 North Pearl Street* Albany, New York 122070 (518)434-45460 Fax:(518)434-0891 Attachment B PERSONNEL AND COMPANY CERTIFICATIONS i i 1 STATPOF NPW,.YQRK `DEPARTi�SEP;IT;OE.i ABOIz' 1SBEST05CERTfEI�A%E'.. - ;GEORGE H.BAILEY ;CLASS(EXPIRES); t ;D:IPISP(10/20),., I 157, ti MUST,BE,'CARRIED'OH-ASBESTOS:PRQJE(�lTS oagammca'RUL >f i + i i i II III t -- IF FOUND RETURN TO: EYES HRO HYSDOL — L&C UNIT M HAIR HRO ROOM 161A SUILDINO 12 `cy$ HCsT 5' 09" STATE OFFICE CAMPUS cq o i C it t290 f • I - I I 1 • r� .rf f New York State Department of Health Certificate of Asbestos Safety Training rs_1 This form is the official record of successful completion of a New York State accredited asbestos safety training-course. �r 70.199 ' Certificate No. .:'S: - 3_t'S.=^i`el:: ':LL%1't•'4'<> - rF:. rj�''� _ =I.. �Q€�e�'`-oaiai,'�e odd`."�`.l'a'heeda;:�:�.�.�; •��,.:_...��;::::.;;,>„ Name of Trainee(print).,. NYS Depart.of MotorVehicles ID(DMV ID) •-� ��1,'�" t•• {.,i w fL;•i. t � ( ti 1 �� .r7 J �•:�� � l6f r_-� Signature of Trainee Telephone Number- Date of Birth' J1 Add i � llF� i�u'i�•jl.,'.`.x •�"1 �,).`_.t••i,.•, ,'_3:`_. � !� ��'i !.' �3'(� `/ I �,� e,... Street or PO Box (City) (State) (Zip 6ode F Sri: II=To..be coa�.. .Trarp_m Provider's Name Telephone Number f'= Arc f=r Address Course 104 EAST 26TH STREET,8TH F L NEW YORK,NY 10010 Location: if 1 �. j i r)• � Zip Code PMDOHttse only Course Title: •�1�' . t- �L'1 ❑ initial Refresher Q DOH Equivalency s Training Language: English[1 Other: Exam Grade./Date: j �� Vq/ Dates of Trainin °From• r1/0 /,� To:- 10/ / '0 Expires: I'c that the asbestos safe trainin course ertify ty g guyea on the above date complied with both 1•'0 lVYC1tR Part 73 and •TSCA Titlet, was consistent with the curriculum aiicl•instructors approved by the 3�Te ' 'I I State Department of t'== Health,and the trainee receiving this certificate completed.tlietsaining course and success ' 'y p ed the examination Training DirecforZi t`1; i , : f'f; ,:' 1 ,�.'� ? ' l� = '. • (print) ` . •+j i tute) STUDENT ..; =:E DOH-2832(10/03) Optional Information 2 DOH Equivalency signed by NYS DOH representative only Fr_: • l�`j Y.•: ff� .....w [�... ..., s.. ......... .. :: ... ..r .".,:•+.'::+5..+.:a . .. • •. ,:r'1.•::...:'J.•.i.;.f•.< !:..:'l•:. ,,..:.P'.'r:-i'r.«:%;1 4H'. .�%%,., :?:✓.?S!.,. ..'rl s,-: :*,r::-i:�;�:;r:,1"!..+ri 7 is 'I Fri ;S f 41 New York State Department of Health Certificate of Asbestos Safety Training This form is the official record of successful completion of ablew York State accredited asbestos safety training course. Certificate No 7 2 le. r� tie . ,ki':<T�� �ne �k�-::�..-:>.;�•:_:.:,...,:.:=�- Naine of Trainee_p*t), NYS Depart,of Motor Vehicles ID(DMV ID) o Signature:dfTrainee /' Telephone Number Date of Birthl V �; }6`1�.rJJlt�,{•(j1,� 4J`„ .� J.. ,y� L rt•� �( .a r u::•. Street or PO Box• Ci State Zi Code .a : Provider's Name Telephone Number ;. .. . . .:;... . . ATC. .• ._ ". ..2,12-3 8-8280 v Address - Course 104 EAST 25TH STREET,8TH FL f =i NEW YOR.K,NY 1Colo Location: ��� k"= I Zip Code 0 { on/ ; a NYE DOHuseonly Courrse Title: V l ( V :Initial'9••Refresher Q DOH Equivalency Training Lanbma e English Other: ate: Grade/D r "f Dates of Training:From: (� /�� / �To• p /1� � 1 g� Gi 1 /: Expires: ((1 !� /.Q I 1 I certify that the asbestos safety training course given on the above date complied with both IO NYCRR Part 73 and i TSCA Title II, was consistent with the curriculum and instructors approved by the New York State Department of Health,and the trainee receivingthis certificate co leted the trainin course d suc =`==mp g ate ss y passed the examination. Training Director : ,JvN.�S �� 5�!<J t�r>;7c7,� � �''- � t'�.• � (Print) (Signature) STUDENT ^=:i 13011-2832(10/03) Optional Information ?-DOH Equivalency signed by NYS DOH representative only i�� - '': • l {JliJ f � r ' _ • .... ., f.•Gk ."1 . .vyLt,..•... .�.i`a 3i-,... .:.h^..tY,t•:•:..•G..:S}f`A �A'7...-� rbi�...?�.; ..';1 S.. :.:s.rili:f,.�%t� r".. i:�rlFj�M.>.�ir„�;�.� �':� . New York State=.Department of Labor- . Division of.Safety and Health.' License and Certiftcate:Unit: State Campus;Building 12` Albany,NY 12240 -ASBESTOS HANDLING LICENSE; _ Adirondack Environmental Services, !lc. FILE NUMBER: 99=0417_ LICENSE NUMBER- 29646 .'314 North Pearl Street ;' LICENSE CLASS: RESTRICTED DATE OF ISSUE: 09/21/2b20 Albany,,NY 12207 : EXPIRATION DATE: 09/30/2021 i Duly Authorized Representative" 'Tara Daniels:;,: _- This license has been issued in accordarice"with"applicable piovisioris'of'Article3V6f the Labor Law of New York State"and of the New"York State Codes,Rules and Regulations',(12 NYCRR Part"56)._ l is subject to suspension or revocation`for a(1) - serious violation of state,federal or local laws with regard to the conduct of"an`asbestos,'project,or(2)demonstrated lack of responsibility inahe conduct of anyjoli'involvmg asbestos or asbestos material:'";. Thislicense is valid only for the contractor named above and tl is license oc`a,photocopy must be„prominently displayed at the asbestos project,worksite.,.This license verifies that all persons employed"by.the licensee on an asbestos project in:New York State have been issued an Asbestos Certificate,appropriate for the type of-work they perform,by the New York State Department of Labor. " 4.1 Jew ''Eileen M.Franko, Director SH 432(8/12) For the Commissioner of Labor United States Department of Commerce National Institute of Standards and Technology Certificate of Accreditation to ISOIIEC 17025:2017 NVLAP LAB CODE: 200552-0 Adirondack Environmental Services Inc. Albany, NY is accredited by the National Voluntary Laboratory Accreditation Program for specific services, listed on the Scope of Accreditation, for.• Asbestos Fiber Analysis This laboratory is accredited in accordance with the recognized International Standard IS011EC 17025.2017. This accreditation demonstrates technical competence for a defined scope and the operation of a laboratory quality management system(refer to joint ISO-ILAC-IAF Communique dated January 2009). Q ANT of 2021-01-01 through 2021-12-31 oy � `� Effective Dates ?� - �e For the National Voluntary Laborator,r�Accreditation Program SATES OF fir. gto OF CO ® National Voluntary Laboratory Accreditation Program y f t4raS SCOPE OF ACCREDITATION TO ISO/IEC 17025:2017 Adirondack Environmental Service_ s Inc. 314 North Pearl Street Albany,NY 12207-1322 Christopher Hess Phone: 518-434-4546 Email: cmhess@adkenv.com http://www.adirondackenviromnental.com ASBESTOS FIBER ANALYSIS NVLAP LAB CODE 20.0552-0 Bulk Asbestos Analysis Code Description 18/A01 EPA--40 CFR Appendix E to Subpart E of Part 763,Interim Method of the Determination of Asbestos in Bulk Insulation Samples 18/A03 EPA 600/R 93/116:Method for the Determination of Asbestos in Bulk Building Materials Airborne Asbestos Analysis Code Description 18/A02 U.S.EPA's"Interim Transmission Electron Microscopy Analytical Methods-Mandatory and Nonmandatory-and Mandatory Section to Determine Completion of Response Actions"as found in 40 CFR,Part 763,,Subpart E,Appendix A. i i i I ' I For the Nat%al Volunta&L borat MCCreditation Program Effective 2021-01-01 th►-ough2021-12-31 Page 1 of 1 . i e nationalgrid D C E U V E 300 Erie Boulevard West Syracuse,New York 13202 MAR 2 3 2021 I October 2,2020, TOWN OF QUEEN BUILDING& CODES RE: Service Removal for Building Demolition. f This letter is to confirm that,per your request,National Grid has confirmed electrical service and meters have been removed from;3 -o +i��,,Queensbury. The work was processed on work request 30177285. Ifyo have any questions or need further assistance,please feel free to contact us at 800-260-0054. Sincerely,; Customer Connections nationalgrid �� to -0 IZVt 'L0 I i 0 Experience is the solution 314 North Pearl Street• Albany, New York 12207+ (518)434-4546♦ Fax:(518)434-0891 I i November 17,2020 Mr. Chris Abele Phone 518-365-4989 Abele Homes 14 Corporate Drive Clifton Park,New York 12065 chris@abelebuilders.com L13 " QRE:Pre-demolition Asbestos Survey and Bulk Sampling 3 2021#3 Po k lZoad ,Qeensbury,-New YorkAdirro d c'P oject No. IH-20-333 j���SBu& CODESRY Mr.Abele: { Adirondack Environmental Services, Inc. (Adirondack)was pleased to provide an asbestos survey and bulk sampling with analysis of suspect asbestos containing materials(ACM) in the residential camp at#3 Polk Road in Queensbury,NY.Attached is a summary report of the survey findings. i Thank you for selecting Adirondack Environmental Services, Inc. for.your asbestos management needs. If you have any questions or require further information, please feel free to contact me at (519)434-4546. Very truly yours, .ADIRONDACK ENVIRONMENTAL SERVICES,INC. Digitally signed by: �p ,p N4 -20 2- George Bailey Date: 2020.11.17 09:31:25 -04'00' GEORGE BAILEY Project Manager Enclosure i '. Asbestos Survey and Bulk Sampling Pre-demolition #3 Polk Road Queensbury, New York Inspection Date November 4, 2020 Prepared for: Abele Builders 14 Corporate Drive U IE C fl V [E -Clifton Park,New York 12065 MAR 2 3 2021 Prepared by: TOWS George Bailey pE BUILDING QUEENSBIJRY Project Manager—Asbestos Services CODES 0 314 North Pearl St Albany,NY 12207 Phone:(518)434-4546 Fax: (518)434-0891 Adirondack Project No.: IH-20-333 239.12-2-35 DEMO-0141-2021 Rockhurst LLC 3 Polk Dr Demolition of camp O AIHA-LAP,LLCAccredited#100307 Experience is the solution NYSDOH#10709 314 North Pearl Street♦Albany,New York 12207 Bulk Asbestos RepOI't (800)848-4983• (518)434.4546 Fax(518)434-0891 Project: Asb Services Abele Homes ProiLocation: #3 Polk Rd Date Sampled: 11/04/2020 14 Corporate Drive Date Received: 11/04/2020 Clifton Park, NY 12065 PLM Analyzed: 11/05/2020 by KAH Attn: ***AES IH Dept*** TEM Analyzed: 11/9/2020 by ktt Method References: NYSDOH ELAI'198.1/198.4/198.6 ReportDate:11/9/2020 Workorder: 201104104 L a Non-asbestos PLM TEM Result Lab y Sample Identification Materials Fibers Asbestos of Residue Final ID a and Description Type (Percent and Type) (Percent and Type)r PLM Result ELAP-198.4 Status 001 A 91-01 Homogeneous, Tar/Roofing No asbestos detected Black,Non-Friable c1% No Asbestos Detected <1% Material Inconclusive** NAC 71 Wt%Remaining PLMMethod: ELAP 198.6 002 A 01.02 Homogeneous, Tar/Roofing No asbestos detected Black,Non-Friable �,/a� No Asbestos Detected <1% Material Inconclusive" NAC 77.3 Wt%Remaining PLMMethod: ELAP 198.6 003 A 02-03 Homogeneous, Tar/Roofing 33.3%Chrysotile 2.7% - 2.7% Black,Non-Friable Material ACM ACM 8.2 Wt%Remaining PLMMethod: ELAP 198.6 Page 1 of 3 ReportDate:11/9/2020 WorkOrder: 201104104 L a Non-asbestos PLM TEM Result Lab y Sample Identification Materials Fibers Asbestos of Residue Final ID e and Description Type Percent and T (Percent and Type) r e ( Type) ce PLM Result ELAP-198.4 Status 004 A 02M- Homogeneous, Tar/Roofing Not Not Black,Non=Friable Material Analyzed Analyzed 2,6 Wt%Remaining PLMMethod:' ELAP.198.6 005 A QL- Homogeneous, Caulk, 44.40/oChrysotile Gray,Non-Friable 21.9% ----••• 21.9% Material ACM ACM 49.4 Wt%Remaining PLMMethod: ELAP 198.6 006 A 03-06 Homogeneous, Caulk Gray,Non-Friable Not Not Material Analyzed Analyzed 50.9 Wt%Remaining PLMMethod: ELAP 198.6 007 A 04-07 Homogeneous, Floor Tile Tan,Non-Friable Material NAC NAC 0 Wt%Remaining PLMMethod: ELAP 198.6 008 A. 04-08 Homogeneous, Floor Tile Tan,Non-Friable <1% <1% Material NAC NAC 0 Wt%Remaining PLMMethod: ELAP 198.6 009 A 05.09 Homogeneous, Floor Tile 50%Chrysotile Tan,Non-Friable 13.8% - 13.6% Material ACM ACM 27.7 Wt%Remaining ,PLMMethod: ELAP 198.6 • Page 2 of 3 © AIHA-LAP,LLCAccredited#100307 Experience is the solution NYSDOH#10709 314 North Pearl Street•Albany,New York 12207 Bulk Asbestos Report (800)848-4963• (518)434-4546♦ Fax(518)434-0891 Project: ProjLoeation: Polk Drive Date Sampled: 10/25/2020 Date Received: 10/2612020 PLM Analyzed: 10/26/2020 by KAH Attn: Chris Abele TEM Analyzed: 10/29/2020 by ktt Method References: NYSDOH ELAP 198.11198.4/198.6 ReportDate:10/29/2020 Workorder: 201026039 L a Non-asbestos PLM TEM Result Lab y Sample Identification Materials Fibers Asbestos of Residue Final ID a and Description Type (Percent and Type) (Percent and Type) pLM Result ELAP-198.4 Status 001 A Polk Ceiling Homogeneous, Other Brown,Non-Friable <i% ......• c1 Material MAC . MAC 0 Wt 90 Remaining PLMMethod: ELAP 198.6 001 B Polk Ceiling Homogeneous, Paint No asbestos detected White,Non-Friable ci% No Asbestos Detected ei% Material Inconclusive" MAC 47.7 Wt%Remaining PLMMethod: ELAP 198.6 ACM:Asbestos Containing Material; NAC:Non-Asbestos Containing Material Approved by: **A negative result for an NOB sample is considered inconclusive.The following NYS ELAP Christopher Hess disclaimer applies:"PLM is not consistently reliable in detecting asbestos in floor coverings and QA Manager similar NOB materials. Before this material can be considered or treated as non-asbestos containing, confirmation must be made using transmission electron microseopy(TEM)". • Page 1 of I O Experience is the solution 314 North Pearl Street♦ Albany,New York 12207♦ (518)434-4546♦ Fax:(S18)434-0891 RECOMMENDATIONS • All ACM must be removed by a licensed asbestos abatement contractor prior to any I activity which would disturb the material. • Although the shingles tested as NAC they will have to be removed in order to abate the underlying tar paper. • The tar paper and chimney caulk may be considered exterior,non-friable material and I can be removed without air testing.Only a visual inspection is required. j • The linoleum the will likely be considered a"small project"which will require related air j sampling. The quantity should be field verified as it is only slightly larger than a"minor size"which would require less air sampling.The quantity reported represents the overall room size but cut-outs for various items may reduce the actual size needing abatement. • Maintain a copy of this report on-site during any asbestos abatement or demolition project as per NYS ICR56-5(g)(3). • Additional bulk samples may be needed for suspect materials that were not evaluated during this inspection due to inaccessibility. This would include any windows which, though assumed to be homogeneous, may be questioned for any reason. • Feel free to contact Adirondack'if you require further asbestos management services. Attachment A contains the laboratory results with chain of custody documentation. Attachment B contains company and personal certifications. This included the current"half- sheet"certification for George Bailey's Inspector Certificate,pending arrival of the actual"hard- card"certificate. Asbestos Bulk Sampling—#3 Polk Road Adirondack Project No.IH 2O-333 3 P a g e r� ff IPA"I MW M,M Experience is the solution 314 North Pearl Street♦Albany,New York 12207t (518)434-4546♦ Fax:(518)43470891 Attachment A LABORATORY RESULTS' AND CHAIN OF CUSTODY �1 { 4 New York State Department of Health Cerffleate of Asbestos Safety Training This form is the official record of successful completion of aNi ew York State accredited asbestos safety training course. (`r Certificate No.8 7 U`.'•. 9� I_To be cotnplet�-d by Trainee •• Flame of Trainee(print) NYS Depart.of Motor Vehicles ID(DMV ID)t Signature of Trainee Telephone Number Date of EiAW Address i Sired or PO Box (City) (State) (Zip 6ade 114o be completed b Traiuin -S onsor i s Provider's Name Telephone Number ATC Address 104E AST 255TH STREET,8TH F Course NEW YORK,NY 10010 Location: j i ! ( t 1•(;� 4 Zip CodeVSDOHL ;= Course Title: .�-t+ I,-:;> ,�` f'. 1 ( ;r ❑Initial, Refresher ElDOH Equivalency Training Language: English❑Other, __Exam Grade/Date: Dates of Training:From. l.1 /'`� /.UTo. (Expires: ( U /-'`! /—.,:7� I certify that the asbestos safety training course given on the above date complied with both to NYCRR Part 73 and TSCA Title 11, was consistent with the curriculum dnd instructors approved by the Nc1v York State Department of Health,and the trainee receiving this certificate completed tfiertraining course acid succcssfy ly pa`ssdd the examination. Training Direcforz. t; } ),-.! ; �.'? 1 i '}. = ., ' (Print) (tSignature) STUDENT i DOH-2832(10/03) Optional Information DOH Equivalency signed byNYS DOH representative only j. • i -S 7 STAm OF-NON Y,ORK ,XPARTN1EhiT,O�'1A80 A igTfJS CER7j61GlTE '.GEORGE H;@Aft.EY CIASSOPIHES7:- 4 . . 4,fPM,�(iolzo) a, MUST BE-CARRIED ON:ASBE$TPS PROJECTS uninwm',cmdiGiia r � i 1 i i i 1 t IINIlIf�lllff!!I!f!(III(f L IF $OUM RBTMR TO: �y$$ 8R0 HYSOOL - L8C UNIT w HAIR BR0 _ BOON 161A BMLVINO 12 t SGY1 5' 0®' STATE OF$I1m CAlms c 1240 I 5 :I i O Experience is the solution 314 North Pearl Street+ Albany, New Yorl<12207♦ (518)434-45464 Fax:(518)434-0891 first positive analysis protocol was followed for each homogeneous set. Samples were submitted to Adirondack for standard turnaround. See Attachments for laboratory, company and personnel certifications. Adirondack is fully accredited for bulk sample analysis under the Environmental Laboratory Approval Program(EL"AP)administered by NVLAP No.200552-0 and the New York State Department of Health, ELAP No.10709. RESULT SUMMARY Materials must contain more than 1%asbestos to be considered asbestos containing material. Three materials;tar paper,chimney caulk and linoleum tile,contained greater than 1%and were therefore classified as asbestos containing material(ACM). j ACM Sample %Asbestos Field Estimate Potential for Sample Location (F,N Total. Condition Disturbance OZ-03,04: Main roof and 2.7% Some Contact:high Tar 4: porch roof Chrysotile, 900 SF damage" Vibration;high p North side NF weathered Air Current:high Between 21.9% Contact:high 03-05, 06: chimney and C sotile, 40 LF damaged Vibration:high caulk exterior wall of NF weathered Air Current:high I cam 05-05, 06 13.8% Contact:high Linoleum Bathroom floor Chrysotile, 30 SF damaged Vibration:high flooring NF Air Current:high F—Friable,NF—Non-friable Materials sampled that contained less then< 1%asbestos are classified as non-asbestos containing(NAC)and included the following: Sample No.and Description ACM Sample Location 01-01,02-Asphalt Shingles Main Roof,main porch roof,north side 04-07,08—Linoleum flooring Kitchen floor 05-09, 10- Brick Mortar North side chimney 06-11,12-Ceiling Board Throughout most rooms 07-13,14—Brick Mortar Exterior Chimney OBSERVATIONS • The camp is in older,somewhat weathered condition but is in reasonably good condition. • The roof is in fair condition with much of it covered in moss and lichen growth.. • No pipes or related insulation were observed. Asbestos Bulk Sampling—#3 Polk Road Adirondack Project No.IH-20-333 2 111 a g c ""M . c, Experience is the solution 314 North Pearl Street* Albany,New York 12207♦ (518)434-4546a Fax:(518)434-0891 EXECUTIVE SUMMARY Mr.Chris Abele,on behalf of Abele Builders,asked Adirondack Environmental Services Inc., (Adirondack)to perform an asbestos survey with related bulk sampling and analysis of the residential camp at#3 Polk Road in Queensbury,NY.The camp is slated for demolition. The purpose of the sampling was to determine if the materials in the structure were asbestos containing material(ACM)which will be disturbed during the demolition..This survey is required in order to obtain a demolition permit from the Town of Queensbury. George Bailey conducted this inspection and collected samples on November 4,2020. Samples were collected as follows: Fourteen(14)samples representing seven (7)homogeneous materials were collected at #3 Polk Road. The materials consisted of typical building materials including roofing-materials,mortars, grouting and flooring materials. By definition and law a material must contain more than 1%asbestos to be classified as ACM. Three(3)of the materials sampled contained greater than(>) 1%asbestos and are therefore classified as asbestos containing material(ACM). The materials included tar paper, chimney caulk and linoleum floor tile found in the bathroom. The remaining materials sampled and analyzed all contained less than(<) 1%asbestos and are therefore classified as non-asbestos containing(NAC)materials. BULK SAMPLE COLLECTION The survey included all observed suspect materials in each of the camp. The inspector,George Bailey,is a NYS certified asbestos inspector. Samples were collected in compliance with NYS ICR56 and EPA's Asbestos Hazard Emergency Response Act(AHERA). A unique sample identification number was given to each homogeneous building material after samples were collected. Bulk sample locations from homogeneous sample areas were selected at random. The number of samples collected for each suspect material was based on the presumed ACM(PALM)type and quantity as required. Samples were placed-into sampling containers and submitted to Adirondack's lab under chain of custody documentation. METHODOLOGY Samples were either analyzed by NYS ELAP methodology via PLM(Polarized Light -Microscopy), PLM/NOB (Polarized Light Microscopy/Non-Friable Organically Bound);or TEM (Trans Electron Microscopy)based on material type as dictated by state regulations. A stop at Asbestos Bulk Sampling-#3 Polk Road Adirondack Project No.IH-20-333 I P a g e 314 North Pearl Street -BULK SAMPLE DATA AND Albany, New York 12207 ' ' • ' 518-04-45461434-0891 FAX CHAIN OF CUSTODY RECORD EXPERIENCE IS THE SOLUTION A full service analytical research laboratory offering solutions to environmental concerns , .v.} Client Name: Address:, Ai E5L?i G Send Report To: Project y�ame(Location): Project Manager: Client Phone No: Project Number: lospectoc; ) Client Fax No: ) (i—Z() " �,G� :a BULK SAMPLE INFORMATION SUN Lab Sample Homogenous TSI Malerlal Analysis In No. Aceaa No. Bulk Sample I}n No./Maleriai MIS Sample Locelien Qty.(LRSF) Reg uesled � Etrl! l-L{' C��`�,� � � y'Li fY.,��' _ �L°r.Z b�.'f•�` r- a i.Y� � `t > 1 — d �� Mimi v, /'a►� s.i :..: 1. (5I\i%AIV U CX) 6 53 365 �kc� 05-i(� Cant`E► 24 6 U\1 —( y 6ri cjL Turnaround Time Request: Special Instructions/Remarks , ? ❑ 1 Day ❑ 3 Day Normal ❑ 2 Day ❑ 5 Day 0 other CC Report To: Relia i ad by:(Sig lure),) Received hi.(Signature) Daie(Iime Rel quishe by:( ignature) Recelv d for Laboratory y: narw/fime WHITE•Lab Copy YELLOW-Samplas Capy 201104104 i { Adirondack Environmental '{ • u ReportDate:l l/9/2020 Workorder: 201104104 L a Non-asbestos PLM TEM Result Lab y Sample Identification Materials Fibers Asbestos of Residue Final ID a and Description Type (Percent and Type) (Percent and Type) PLM Result ELAP-198.4 Status. r 010 A o5-10 Homogeneous, Floor Tile ° Tan,Non-Friable NOt Material Analyzed- Inconclusive" 28.5 Wt%Remaining PLMMethod: ELAP 198.6 011 A 06-11 Homogeneous, Other __..... Brown,Non-Friable ci°10 <7 Material NAC' NAC 0 Wt%Remaining PLMMethod: ELAP 19B.6 012 A AU2 Homogeneous, Other Brown,Non-Friable Material NAC NAC 0 Wt%Remaining PLMMethod: ELAP 198.6 013 A 07-13 Homogeneous, Friable Material No asbestos detected Gray,Friable Material NAC NAC PLMMethod: ELAP 198.1 014 A 7-1 Homogeneous, Friable Material No asbestos detected % Gray,Friable Material NAC NAC PLMMethod: ELAP 198.1 ACM:Asbestos Containing Material �� NAC:Non-Asbestos Containing Material Approved by: **A negative result for an NOB sample is considered inconclusive.The following NYS ELAP Tara Danicls disclaimer applies:"PLM is not consistently reliable in detecting asbestos in floor coverings and similar Laboratory Director NOB materials. Before this material can be considered or treated as non-asbestos containing, confirmation must be made using.transmission electron microscopy(TEM)". Page 3 of 3 314 North Pearl Stiect CHAIN OF CUSTODY RECORD Albany,NY 12207 AES tNork Ordertl: r• �= 518-434-4546 / FAX:S 18 434-0891 :t EXPERIENCE IS THE SOLUTION COO Reference: A full service anntytic:d research laboratory offering solutions to environmental concerns _ .... iClient Name: Address Send Report to: ( i `Project Name(Location): Samplers Name: ........ .......................� ..... ..r-. ... .............. ...... .... .. ... ... ... .. /1 1 Client Phone#: '" ?( y(�y�r Client PO#: Samplers Signah,e: /� :.•.: (Client Email: _. . ....... AES Time (Sample Type #of Preser Sample Client Sample Identification & Date A=am i_. .. Number Location Sampled P=pm Matrix C G on vative Analysis ....................._...... _............. - -.... II.. S.I.. I `'Irk �s y I i _ _[............ ..................... .. .I..._.__..-._.. -I_ L_P.I....... .... ..............f.... 1............... . . ._.._ �.•........._I...P.I..... ... I . .I. ._I. �.... , A PI I, L. ._[.............L......_ .L... .......... __ , I. I I P I_.... ....._,._I_ I.......L_.._._...L_ _.....L.._................_..__ I _.... ....._...,......_._.............._... ._. I ,._.....-...__. L. L_P............ L_.._ .__....I........L.... I__.......I. ....._......I--............ .. . . . A ' P A P P ! _ ..-.. w_................ ._..._.......,.,... .._....•.. ....._._w_ ...,...__.. . .._.._ _ ...... ._..._ - ....._ ...............- ....... _._ ......... ._ I_P_.L.- -I--_..I... L.._r.. l_.....__ti..1._...._..------_..___�_w._......._......_ p _ Shipment Arrived Via: Special Instructions/Remarks: FedEx UPS .'Client. 'AES Other: Turnaround Time Requested: c R ✓� a 01 Day 02 Day 3 Day 5 Day Standard r NOTE*Samples received it 3:30pm are c9 s, d mess day. Relinquished by:(Stgna Received by:(Signature) Date Time Relinquished by:'(Signature} (Received by:(Signature) Date Time L } Relinquished by:(Signature) Re iv e ab y by: , Date time Sample Temperature Properly Preserved• N Received Will hin Holding Chilled - Chilling Begun O=None 5=NH401 Times / N or:es! 1=W2SO4 pH<2 6=Ascorbic Acid Notes: 2=HNO3 pH<2 7=FAS 3=HCI pH<2 8-ZnAc/NaOH pH>9 4=Na2S203 9=NaOH pH>10 Custody Seal Inta t: Y N to=other -.. M Bottles AES _ 1 N V 201026039 f iNew York State De arOnent of Health Certificate of Asbestos Safety Training 17tis four is the official record of successful completion of a New York State accredited asbestos safety training course. Certificate No U.1 9 9 _ Z-To'be completed by Trainee Name of Trainee(print). NYS Depart.of Motor Vehicles ID(DW ID)' �.t ram• , � { �.! •'+t�' -f l.J• ;:i Signature of Trainee Telephone Number Date of Birth' jAddress (Street or PO Box) Cit ((Stale) 7_i Code) 3 lI—To be completed b Training S ousor Provider's Name Telephone Number ATC 212. 53.8280 -- t7P-SERVICES •; �;:: Address Course 404 EAST 25Tii STREET;8-TM F NEW YORK,NY 10010 Location: Zip Code �- , NYS D use ant, xl Course Title: .L�-� �, '�}- ( "(,.'t' Initial Refresher ❑DOHEquivaleacya i i •r Training Language: 'English El Other. Exam'Grade/Date: ; r! ,� �'i''/ Dates of Training:From: I r To: { /; 1(,.t Expires: I certify that the asbestos safety training course given on the above date complied with both 1-0 NYCRR Part 73 and TSCA Title H, was consistent with the curriculum end instructors approved by the Nov York State Department of Health,and the trainee receiving this certificate completed the.1raining course atid'siiccessFEily p�ssed the examination. TrainingDirecforz. (Print) (Sitiature) STUDENT DOH-2832(10103) t Optional Information a DOH Equivalency signed by NYS DOH representative only • 9 :t 'h .:j 'J STATE OF MEW`(ORK DEPaRTI�EFIT,OF'LAQOR 158ESTQSEfRTIFICATE:':' - I' aEORGE.H,BAILEY CIASS(EXPIBES)'•. , I ',CATEC(i3OI20) O.INSP(1P17D) f!•.•vl3 psi` _ r'S" MUST BE,CARRIED ON AS(SESTOS PROJECTS ntnroi�i��nntcaia i , 1 I f I HIM IM 111111 lllllll 11 it 11111 IF HOUND RBTMM TO: EYES HRO NY9D0L - L&C UNIT HAIR WO RMM 161A B=LDTNO 12 NOT 51 09" SV,AT$ OFFIM CAMUS T 1240 cv c A: I 1 United States Department of Commerce National Institute of Standards and Technology F\kfl Certificate of Accreditation to IS®IIEC 17025:2005 NVLAP LAB CODE: 200552-0 Adirondack Environmental Services Inc. Albany, NY is accredited by the National Voluntary Laboratory Accreditation Program for specific services, listed on the Scope of Accreditation, for. Asbestos Fiber Analysis This laboratory is accredited in accordance with the recognized Intemational Standard ISOAEC 17025.2005. This accreditation demonstrates technical competence for a defined scope and the operation of a laboratory quality management system (refer to joint ISO-ILAC-IAF Communique dated January 2009). OX OF 2020-01-01 through 2020-12-3 1 Effective Dates %,� OF For the lVational Volunta Labora6q&ccreditadon Program OC74TES OF P� �; �01 OF CO, National Voluntary Laboratory Accreditation Program MY `FATES OF P SCOPE OF ACCREDITATION TO ISO/IEC 17025:2005 Adirondack Environmental Services Inc. 314 North Pearl Street Albany,NY 12207-1322 Mr. Sean Wells Phone; 518-434-4546 Fax: 518-434-0891 Email; swells@adirondackenvironmental.com http://www.adirondacicenviromnental.com ASBESTOS FIBER ANALYSIS NVLAP LAB CODE 200552-0 Bulls Asbestos Analysis Code Desct•rption 18/A01 EPA--40 CFR Appendix E.to Subpart E of Pail 763,Interim Method of the Determination of Asbestos in Bulk Insulation Samples 18/A03 EPA 600/R-93/116:Method for the Determination of Asbestos in Bulk Building Materials Airborne Asbestos Analysis Code Desci-4)don 18/A02 U.S.EPA's"Interim Transmission Electron Microscopy Analytical Methods-Mandatory and Nonmandatory-and Mandatory Section to Determine Completion of Response Actions"as found in 40 CFR,Part 763,Subpart E,Appendix A. I� For the National VoluntaAA L borat %Accreditation Program Effective 2020-01-01 through 2020-12-31 Page I of I I> i New York State—Department of Labor Division of Safely and Health License and Certificate Unit State Campus.Building 12 Albany,NY 12240 ASBESTOS HANDLING LICENSE Adirondack_ Environmental Services, Inc. FILE NUMBER: 99-0417 LICENSE NUMBER: 29646 314 North Pearl Street j LICENSE CLASS: RESTRICTED DATE OF ISSUE: 09/21/2020 Albany,NY 12207 EXPIRATION DATE: 09/3012021 Duly Authorized Representative—Tara Daniels: f This license has been issued in accordance wittn;applicable provisions of Article30.of the Labor Law of New York State and of the New York State Codes;Rules and Regulations(12 NYCRR Part 56). It is subject to suspension or revocation for a(l) serious violation of state,federal or local laws with regard to the conduct.ofan asbestos project,or(2)demonstrated lack of responsibility in the conduct of any job,involving asbestos or asbestos material. This license is valid only for the contractor named above and this license or a photocopy must be prominently displayed at the asbestos project worksite. This license verifies that all persons employed by the licensee on an asbestos project in New York State have been issued an Asbestos Certificate,appropriate for the type of work they perform,by the New York State Department of Labor. Eileen M.Franko, Director SH 432(8/12) For the Commissioner of Labor. • i . fl l{ �t I, 1. .-q New York State Department of Health Certificate of Asbestos Safety Training This form is the official record of successful completion of a New York State accredited asbestos safety training coma. Certificate,NoB 7 2:1 2' 1—To be completed by Trainee. Na#ue of Trainee(�rinq NYS Depart.of Motor Vehicles ID(DMV ID)t Signature df Trainee ( Telephone Number Date of Birth' A!d¢,r!ess f -+ 4� ( ,�` "� • ".�. �f '�.� i' I �i'tlr :(�t• I ,'-,} 1 �Y. Street or PO Box) (City) (State) (Zip Code) Q—To be completed by`i'rauliiie Spousor I Provider's Name Telephone Number ? _ ATC �`—GROUF 2,i2-3 3�828 Address Course 104 EAST 25TH STREET,STH FL ( " NEW YORK,NY 10010 Location: (_Af i !`;t,-• Zip Code y�l _ ` i^``I NYS DON use o+rly Course Title: _ y a Initial Refresher ❑DOH Equivalency Zr Training Language; ]English[]other: Exam Grade/Date: ':;J_'/'; i �� Dates of Training:From: t 1 I A.1 �To; �� /i I/�c tr' Expires: 1 r,1 /1 I -- -- I certify that the asbestos safety training course given on the above date complied with both 10 NYCRR Part 73 and TSCA Title Il, was consistent with the curriculum and instructors approved by the flew York State Department of i i Health,and the trainee receiving this certificate completed the training course and,suc&SAIlly passed the examination. Training Director: -i0:1n, (Print) (Signau m) STUDENT DOH-2832(10103) t Optional Information 2 DOH Equivalency signed by NYS DOH representative only e i h I',i