B Illustrations – Inspection and Management Plan Forms

Section 855.APPENDIX B   Illustrations – Inspection and Management Plan Forms Section 855.ILLUSTRATION B   Inspection Report Form Category Sample Area I.D. Inspection Date School I.D. # School Name School Address City State Zip Room(s) Sample Numbers Inspector Name(s) and I.D. #(s) Location of Area: Description of Material Sampled: Friability: High Moderate Low Area Estimate: Ft. Water Damage: Yes No Pipe Diameter: In. Physical Damage: Heavy Moderate Low None Type of Wall: Smooth Concrete Gypsum Board Textured Concrete Masonry Other Type of Floor: Concrete Carpet Tile Wood Other Type of Ceiling: Acoustic Tile Exposed Structure Textured Plaster Accessibility: Height of friable material from floor: Ft. Existence of barriers: Suspended Ceiling E ncapsulation Other Proximity to items requiring maintenance: Electrical V entilation Plumbing Other Less than 1 Ft. More than 1 Ft.-Less than 5 Ft. More than 5 Ft. Ventilation Systems: Vents near friable material: Yes No Distance Ft. Return Grille Supply Grille Air Movement: Heavy Moderate Low Activity and Movement: Use of Room: Activity: High Moderate Low What is above the room? What is adjacent to the room? Comments: