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Asbestos Bulk Sample Form

Building: _____________________________ Date: __________________________________
Sampler: ________________________________________

         
Pipe/Tank
 insulation
 elbow
 transite pipe
 gasket
 tank insulation
Flooring
 12x12 tile
 9x9 tile
 linoleum
 mastic
Structural
 fireproofing

HVAC
 insulation
 tape
Ceiling
 popcorn
 textured
 suspended tile
 glued-on tile
 mastic
Wall
 sheetrock
 textured wall
 transite panel

Roofing
 shingle
 rolled
 felt
 tar
 transite shingle
Misc
 transite siding
 lab bench
 window putty
 other: _______
______________
______________
 

Sample No.:
Color: _____________________
Quantity: ___________________

Floor: __________
Room: __________
Location: N S E W
 Wall Floor Ceiling
Above ceiling
Other: ___________

Description: _______
__________________
__________________
__________________

Pipe/Tank
 insulation
 elbow
 transite pipe
 gasket
 tank insulation
Flooring
 12x12 tile
 9x9 tile
 linoleum
 mastic
Structural
 fireproofing		 HVAC
 insulation
 tape
Ceiling
 popcorn
 textured
 suspended tile
 glued-on tile
 mastic
Wall
 sheetrock
 textured wall
 transite panel		 Roofing
 shingle
 rolled
 felt
 tar
 transite shingle
Misc
 transite siding
 lab bench
 window putty
 other: _______
______________
______________
 

Sample No.:
Color: _____________________
Quantity: ___________________

Floor: __________
Room: __________
Location: N S E W
 Wall Floor Ceiling
Above ceiling
Other: ___________

Description: _______
__________________
__________________
__________________

Pipe/Tank
 insulation
 elbow
 transite pipe
 gasket
 tank insulation
Flooring
 12x12 tile
 9x9 tile
 linoleum
 mastic
Structural
 fireproofing		 HVAC
 insulation
 tape
Ceiling
 popcorn
 textured
 suspended tile
 glued-on tile
 mastic
Wall
 sheetrock
 textured wall
 transite panel		 Roofing
 shingle
 rolled
 felt
 tar
 transite shingle
Misc
 transite siding
 lab bench
 window putty
 other: _______
______________
______________
 

Sample No.:
Color: _____________________
Quantity: ___________________

Floor: __________
Room: __________
Location: N S E W
 Wall Floor Ceiling
Above ceiling
Other: ___________

Description: _______
__________________
__________________
__________________

Pipe/Tank
 insulation
 elbow
 transite pipe
 gasket
 tank insulation
Flooring
 12x12 tile
 9x9 tile
 linoleum
 mastic
Structural
 fireproofing		 HVAC
 insulation
 tape
Ceiling
 popcorn
 textured
 suspended tile
 glued-on tile
 mastic
Wall
 sheetrock
 textured wall
 transite panel		 Roofing
 shingle
 rolled
 felt
 tar
 transite shingle
Misc
 transite siding
 lab bench
 window putty
 other: _______
______________
______________
 

Sample No.:
Color: _____________________
Quantity: ___________________

Floor: __________
Room: __________
Location: N S E W
 Wall Floor Ceiling
Above ceiling
Other: ___________

Description: _______
__________________
__________________
__________________

Directions

  1. Use a separate page for each building.
  2. Fill out one section for each sample taken. Provide as much information as possible.
  3. Use a unique sample number as provided by Facilities Operations administrative staff for each sample.

NOTE: if multiple samples are being taken of a homogeneous material, use the same unique number, and place a letter qualifier behind it for each sample, i.e., B4032a, B4032b, Bfo32c, etc.