Asbestos Work Permit

Asbestos Management Program Properties Under Management Of University Of Winnipeg Asbestos Work Permit - Revised - April 24, 2013

N o t i c e : Permit # A l l w o r k s h a l l c o n f o r m t o f e d e r a l , p r o v i n c i a l , m u n i c i p a l s t a n d a r d s , c o d e s a n d g u i d e l i n e s a n d t h e r e q u i r e m e n t s s e t f o r t h i n t h e a s b e s t o s m a n a g e m e n t p r o g r a m f o r t h e U n i v e r s i t y o f W i n n i p e g o r a n y p r o j e c t s p e c i f i c a t i o n s p r e p a r e d . I n t h e c a s e o f a c o n f l i c t i n a n y o f t h e a b o v e n o t e d d o c u m e n t s , t h e m o s t s t r i n g e n t s h a l l a p p l y.

Information Physical Plant or APM: Contact: Phone: Email:

Date Of Request: A. Start Date: B. Anticipated Completion C. Actual Completion Date: Date:

Location Of Building: Description Of Work:

Building Room #:

Work To Be Completed [ ] U Of W Trained [ ] Pre-Qualified Contractor [ ] Other Contractor: (note By: Employees Specify: evidence of training must be attached) Specify: Project Related To: Project #: Project Manager:

Procedures Item (to be completed by Originator) Requirements (to be determined by APM) [ ] S p r a ye d F i r e p r o o f i n g [ ] Type 1 [ ] Type 2 [ ] Textured Ceiling Or Wall Finish [ ] Type 1 [ ] Type 2 [ ] Plaster Or Asbestos Cement Panels [ ] Type 1 [ ] Type 2 [ ] Contaminated Area (Ceiling, Crawlspace, Shaft, [ ] Type 1 [ ] Type 2 Chase, Etc) [ ] Ceiling Tiles [ ] Type 1 < 10 Tiles In One [ ] Type 2 > 10 Tiles In One Location Location [ ] Flooring [ ] Type 1 Tiles [ ] Type 2 Sheet Goods [ ] Doors [ ] Replace Only [ ] Disposal As Type 2 [ ] Pipe/Duct Insulation [ ] Type 1 [ ] Type 2 [ ] Type 3 [ ] Debris Clean Up [ ] Type 1 [ ] Type 2 [ ] Type 3

O t h e r C o n t r o l F a c t o r s [ ] E v e n i n g W o r k S p e c i f y H o u r s : [ ] I n s p e c t i o n A n d A i r M o n i t o r i n g R e q u i r e d

[ ] D a y W o r k S p e c i f y H o u r s : [ ] A r r a n g e m e n t s M a d e F o r I n s p e c t i o n s b y : S p e c i f y : [ ] W e e k e n d W o r k S p e c i f y H o u r s :

[ ] R e l o c a t i o n O f S p e c i f y A r e a To B e [ ] R e s t r i c t e d A c c e s s To W o r k A r e a B y O c c u p a n t s O c c u p a n t s R e q u i r e d R e l o c a t e d : S p e c i f y A r e a :

[ ] H VA C S h u t D o w n S p e c i f y H o u r s A n d Z o n e s : [ ] O t h e r S y s t e m S h u t d o w n

S p e c i f y : N o t i f i c a t i o n N o t i f i c a t i o n s S e n t To : D / M / Y: [ ] W o r k p l a c e S & H ( Ty p e 3 O n l y ) D a t e : [ ] A P M D a t e : [ ] B u i l d i n g Te n a n t s D a t e : [ ] D e p a r t m e n t H e a d D a t e : Ap p r o ve d B y:

Ap p r o ve d D a t e : D a y/ M o n t h / Ye a r :