Free Asbestos Occupant Protection Plan, F-44016 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Public Health F-44016 (Rev. 03/09) Page 1 of 1

STATE OF WISCONSIN Bureau of Environmental and Occupational Health DHS 159, Wis. Adm. Code

ASBESTOS OCCUPANT PROTECTION PLAN
This occupant protection plan shall remain posted for the duration of the asbestos project. Only certified persons using appropriate personal protection may enter regulated areas.

Contractor - Describe the actions taken to ensure the health and safety of building occupants during this project in space below.
If handwritten, write clearly and legibly. Post this plan in plain view outside the regulated area for the project.

Occupants ­ Asbestos is a hazardous substance. The actions described below are meant to protect you and others

nearby during this asbestos removal project. It is important to stay out of work areas while work is in progress and until permission is given to re-enter upon completion. The contractor will do daily clean-up, but the regulated work area may still contain dangerous levels of asbestos until final cleaning is completed.
ASBESTOS COMPANY INFORMATION Company Name Address Company Contact Person ASBESTOS PROJECT INFORMATION Property Type or Property Name Address Property Contact Person Project start date (mm/dd/yy) Project end date (mm/dd/yy) City Telephone No. ( ) Project work shifts am pm City Telephone No. ( ) DHS company No. State Zip Code

night

PROJECT DESCRIPTION (Type of project, including type and amount of asbestos-containing material)

PROTECTIVE MEASURES (Describe below actions taken to ensure occupant safety ­ attach additional sheet, if needed) Containment or barrier system (including negative air system, glovebag, full containment, mini-containment, etc.)

Ventilation system shutdown

Work practices (such as wet methods, debris-lowering system, waste handling)

Final cleaning and clearance description (such as air scrubbing, HEPA vacuuming, wet cleaning, encapsulant, air sampling)

DEPARTMENT OF HEALTH SERVICES ­ ASBESTOS PROGRAM CONTACT Asbestos and Lead Section ( 608 ) 261-6876