New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

Environmental and Occupational Health Assessment Program

P. O. Box 369, Trenton, NJ 08625-0369

ASBESTOS MANAGEMENT PLAN

STATEMENT OF ENSURANCES
FOR STATE USE ONLY
Name of Responsible Governing Authority

Name of Facility

Building Assessed

The undersigned does hereby ensure and certify that:

1.	This management plan has been developed, signed and submitted by an accredited management planner as required by current law and regulation.

2.	The activities of any person(s) who perform(s) inspections, re-inspections, periodic surveillance, develop and update management plans, and develop and implement response actions, including operations and maintenance, are carried out in accordance with current law and regulation.

3.	All custodial and maintenance employees are properly trained as required by current law and all other applicable Federal and/or State regulations, e.g., the Public Employee Occupational Safety and Health Act, the EPA worker protection rule, or applicable state regulations.

4.	All workers and building occupants, or their legal guardians, are informed annually, pursuant to current law and regulation regarding inspection, reinspections, response actions, post‑response action activities, including periodic reinspection and surveillance that are planned or in progress.

5.	All short term workers who may come in contact with ACBM in the building are provided information regarding the locations of ACM and suspected ACBM assumed to be ACM. Compliance with this requirement shall be accomplished through the preparation and distribution of written material to all short term workers accessing areas where they may come in contact with ACBM.

6.	All warning labels, signs and notices are posted as required by current law and regulation.

7.	All management plans are available for inspection and notification of such availability has been provided as specified by current law and regulation.

8.	The undersigned person (asbestos program manager) designated by the responsible governing authority has received training as required by current law and regulation.

9.	The asbestos program manager has and will consider whether any conflict of interest may arise from the interrelationship among accredited personnel and whether that should influence the selection of accredited personnel to perform activities necessary to develop and/or implement this management plan.

10.	All laboratories utilized for the development of this management plan meet applicable requirements as provided for by current law and regulation.

11.	The Responsible Governing Authority maintains a copy of the asbestos management plan submitted to NJDHSS in it's administrative office to be updated at least once every 6 months with all prior information retained.

12.	All persons who design or implement response actions, except for O&M activities, are licensed pursuant to NJAC 8:60-8 or by another state that has a reciprocal agreement with New Jersey.

13.	Proper cleaning has taken place at least once after each inspection and before initiation of any response action other then operations and maintenance activities or repair, unless the building has been cleaned using required methods within the previous 6 months.

14.	All abatement work except for operations and maintenance activities is performed in accordance with the Asbestos Hazard Abatement Subcode of the Uniform Construction Code (NJAC 5:23-8).

15.	The management plan shall be maintained for a period of no less than 30 years after the building is demolished, shall be updated to keep it current with all asbestos related activities and shall include the following information:

a.	For each preventive measure or response action taken, a detailed description of the activity, location, reasons for selecting activity, start and completion dates, names and addresses of all contractors and ASCM firms and their respective accreditation credentials (including copies of licensing documents), and if ACBM is removed the name and location of the storage or disposal site.
b.	For the completion of response actions, the name and signature of each person collecting air samples, the exact location where each sample was collected, date of collection, name, address, and telephone number of laboratory, date of analysis, results of analysis, method of analysis, name and the signature of person performing the analyses.

c.	For required staff training, each person's name, job title, date of training, training agency, course name, place and hours of training and a copy of each persons certificate of completion, if applicable, for each course taken.

d.	For required cleaning, the name of each person performing the cleaning, and location of cleaning and methods used.

e.	For each operations and maintenance activity performed, the name of each person completing the activity, the start and completion dates, the location of the activity and if ACBM is removed, the name and location of the storage or disposal site.

f.	For each fiber release episode, the date and location of the episode, the preventive measure or response action taken, the name of the person(s) performing the work, and if ACBM is removed, the name and location of the storage or disposal site.

16.	The following information is included as part of the management plan submitted to the Asbestos Control Service and is properly filed in the administrative office of the Responsible Governing Authority:

a.	A listing of the name, address, affiliation (if applicable), signature and accreditation credentials including copies of licensing documents, of the following persons: inspectors/assessors, management planners.

b.	A description of assessments of all ACBM and suspected ACBM assumed to be ACM.

c.	A blueprint, floor plan, or diagram of each building that clearly identifies each location and approximate square or linear footage of homogeneous areas of friable suspected ACBM, non‑friable ACM, and friable and non‑friable suspected ACBM assumed to be ACM.

d.	Substantiating data submitted as indicated on NJDHSS management plan forms.

e.	The name, NJDHSS certification identification number (if applicable), address, and telephone number of any laboratory that analyzed bulk, surface, and air samples, the date of collection, date of analysis and name and signature of the collector and person analyzing the samples.

f.	Copies of chain of custody forms and laboratory analysis forms for each sample.

g.	Plans and specifications for response actions.

h.	A plan for reinspection at least once every three years after the management plan is implemented.

i.	A plan for operations and maintenance activities, including periodic surveillance.

j.	A listing of additional cleaning recommended in conjunction with operations and maintenance activities and the response to the recommendations.

k.	A detailed description of the steps taken annually to inform maintenance personnel, building occupants and children’s parents or legal guardians regarding:

‑ Inspection

‑ Re‑inspection

‑ Response Actions

‑ Post Response Action Activities

‑ Periodic Reinspection

‑ Surveillance Activities that are planned or in progress

‑ A detailed description of a chain of command including delegation of responsibilities and procedures for reporting, obtaining supplies and storage and disposal of asbestos wastes

l.	Previous/current Asbestos Abatement Log.

m.	An evaluation of the resources needed to complete response actions successfully and carry out reinspection and operations and maintenance activities.

n.	A description of a chain of command including delegation of responsibilities and procedures for reporting, obtaining supplies and storage or disposal of asbestos waste.

I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully or intentionally false, I am subject to punishment.
Name of Asbestos Program Manager

Signature	Date

Address

Phone Number

( )

ASBESTOS MANAGEMENT PLAN

STATEMENT OF ENSURANCES, Continued

ASB-19

MAR 13	Page 2 of 2 Pages.

MAR 13	Page 1 of 2 Pages.

Q

ASB-19, Asbestos Management Plan, Statement of Ensurances

ASB-19, ASB, AMP, asbestos management plan, statement, ensurances, CEOHS, EEOH, consumer, environmental, occupational, epidemiology

Elaine White

2004-12-20

ewhite

NJDOH