Reasonable Certainty
of Non-Disturbance of Asbestos

For any WSU public works project, the Project Officer, Architect, Engineer, Project Leader or Construction Supervisor primarily responsible must complete and sign a form which contains the above title and specifically states that asbestos disturbance is not expected to occur. Alternatively, this form can be used. If no suspect materials will be disturbed, check or circle "No Asbestos Disturbed" in Item 1 below, sign the form, and provide a copy of the signed form to all bidders on the project. Otherwise, check the items listed below in Item 2 which may be disturbed, sign and place this form in the project file, and arrange for a good faith inspection of the project. A copy of the good faith inspection report must then be made available to all bidders on the project as well as to any employer whose employees are in the immediate vicinity of abatement work associated with this project.

The project only involves materials made of metal, glass or wood, or else, if the project involves any material listed below, the material will not be disturbed by project activity.
			No Asbestos Disturbed
The project involves one or more of the following materials, which may be disturbed by project activity (check each item).

Linoleum	Vinyl Floor Tile	Flooring Mastic	Baseboard Mastic
Drywall	Wall Plaster	Wall Texture	Loose Insulation
Ceiling Tile	Popcorn Ceiling	Textured Ceiling	Siding Shingles
Roofing Tar	Roofing Shingles	Pipe Insulation	Pipe Gaskets
Boiler Insulation	Tank Insulation	Woven Gaskets	Fireproofing
Fume Hood	Oven	Furnace	Transite Panels
Panel Adhesive	Transite Water Pipe	Transite Steam Pipe	Underground Panels

Certification I certify that to the best of my knowledge, the above-provided information is correct. Signature:________________________________________________________

Typed/Printed Name, Address and Telephone Number of Person Signing This Form:

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________