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ASB06-0023 PRJ06-0187.pdf
___ APPLICATION WILL NOT BE ACCEPTED IF INCOMPLETE OR UNSI�_\ Q (p - � � Q � � ��� � � � � Project #: ` �VJ Building Permit #: T � �' Asbestos Permit #: � ' � �� �� �� ���' TOWN OF VAIL ASBESTOS ABATEMENT PERMIT AP C TION �� � Required per Ordinance No. 19, Series of 1998 75 5. FronWge Rd. Permit application will not be accepted without the following: Vail, COlorado 81657 1. Copies of General Abatement Certifcate and State of Colorado Certifcation 2. A mpy of written arrangementr with the facility operators for any temporary disabling of the air handling systems, fre sprinkler system, and alarm systems with the names and mntact phone numbers of [hese individuals. 3. Site plan with details addressing: waste container storage location. waste load out area location. entry and exiting details of abatement area. details of entry and exiting plans for the occupants of the structure in unaffected areas. CONTRACTORINFORMATION On Site Abatement Contractor. Town of Vail Reg. No.: Contact and Phone #'s: ( JGIYY"- �Dy� RZ�Y 1� ., : � 0 L � , _ Li " ., ' 1 � Q - � T7C q " ll ' , . �-- E-MailAddress: .jD��¢rr�C�& — Ei-�v � rf� CO �'Yl Contrac[or Signature: � .�r� �"_. - - �- - COMPLETE VALUATION FOR ASBE5T05 ABATEMENT PERMIT (Labor & Materials) Asbestos Abatement: $ "� y( �+, G�' Contact Ea /e Coun Assessors O�ce at 970-328-B640 or visit www.ea le-count . com for Parce/ #' Parcel # �, o I - O - `lo� l - 1 Job Name: Job Address: � �' } (�or \ec�4G�(�. C'�q �C�,=C_iA�QC �' � �_ �'C ' ��Q � 1— �. l_n 1 iGj . Legal Description Lot: Block: � Filing: Subdivision; Owners N�me: , , Addre1 : ,� , � . , Ph�e,; , i . _ . � . Pro�e Mand9er: Addr s '. ��(W� �2:p-� ( C. Ph. ne: � �, ,, -� -r oe�t � c�� �� � - - �� .° � P o� .pesi er: d �ess� `�'�"i ��� e: �.� - .� � � �> p � �_ � C � _ AirMOmtor gSpECialist: Addrss: . kle�tEF( L one: � �-'L . � .., �, 7. . §- �> DetaileddescriptionoPwprk: ���'E-��rv rY�v��� c� q,n �X�_�7V c� R_a��F ;�-,�_-, •�p���� (� � i � ti �L. S1� v - .,�( ..��-ZLPC�sY , �>IY-c�{ (-tC:Co- cil�7 S1�lA� l 'sPIC�- �vi � cl5> �. lctrlr �l'l . SCartDate: C� ���� �-z� x �� EndDate: �� �-i.�, � �.cc(n StartTime: � U(:� e�,�� QWtTime: � - 3(% P�� Amount of Asbestos Linear Feet 1(1`r, Square Feet: _�� 55/Gal Drums: Work Qass: New ( ) Addition ( ) Remodel Repair ( ) Demo ( ) Other ( ) Work Type: Interior�) Exterior O Both O T e of Bld .: Sin le-famil . Two-famil Multi-fami Does a Fire Alarm Exist: Yes O No . )� Does a F Yes O No . -) x.:u �ar:ax.a..e++�...�,v.u�a+,v�+eax�,u�,vr,.�.+FOR OF�'yE ++e: �.0 �,u���xc�+,v:r :va��a.. Other Fees: Date Received: `s �, f C Public Wa Permit Fee: Acce ted B ? � _ Occu an Grou : � � ' ' " �. f� C:\DOCUments antl Settings\Ryan ]un9\LOCaI Settings\Temporary In[emet Files\OLK29\asbestos_Oerm_12-5-0iDOC Page 1 0( 2 12/OS/2405 ol � r� � e art � r� � �f ub [ � c ealth � nvirc� � er� t Air Pallutic� r� Cc� ntrol division � Stationary � ourc�s Progr� m -- Indoor Air Unit 4300 Cherry � reek Drive South , APCC�- 55� � 1 , , ;: :, , , , , ; , Denver, � olorad � 80246- 153 � `�` `"� '' `� � � �'hone : 303-692-3100 -� �ax : 303-7� 2- 027�3 E - mail : asbestos@ �ta�e . cc� . u � This permit is graneed suUject to Colorado Air Quality Control Commission Regulation No. � , Part B , adopted December 16 , 2003 , and effeceive March 2 , 2005 , the Colorado Air Pollution Prevention and Control Act C . R. S . (25 -7� 101 and 25 -7-501 et seq) and the following provisions . It is only for the pur•pose of aliowing asbestos abatemenC. .�DDIT � OIVAL. PERIV[ I'I' �12f�VI �IONSe By pef�forming work under this permit the abatement contractor agrees that the Division may revoke or suspend this permit should the Division find that the contractor: � has violated of- has aided and abetted in the violation of 25 -7-501 or 25 -7-501 et seq . , C . R. S . or Rebulation No. 8 , or an order of' the Division or Commission, • has failed to meet any permit and notification requirement or failed to con•ect any violations cited by the Division during any inspection with �n a reasonable period of time, as tnay be detennined by the Division, � has used misrepresentation or fi•aud in obtaining this permit, or, � has committed any act or omission v��hich does not meet generally accepted standards of the practice of asbestos abatement. As a contz•actor, you may be subject to other licenses and pennits, depending on the requirements of the county and municipality in which the work is being pei•formed . The Colorado Department of Public Health and Envirotunent, Air Pollution Control Division sh�ongly suggests that you check with county and mu�� icipal authorities in order to determine any other local building/permitting requirements that must be met. T' � E �F�I � INA � �E IT' l�II1ST' � E PE� S'TE � � � �IT' � ��` t� I,I, � �I�I � � o �'a�ad're�li�dPely rdotifj> t�'re [Ir�iP of projecP srrord�c�etioets by fnx («r�rr�ber rcbove) ow e-�yzrril (c�cCcl�ess �rhove) and t/re rrpprogrirate <'����aP�� hecllilr r�eprcrt$�aeeg6 b,y �!l.Eo �POf2Cf FF&�(�f�CC`P!(�idS 1f1C�liA�° C68CdlF�@� dtt fE2 � SCO�`3� Q� 04�l1d'�6 �Y' fAdL' SC!F �:�[6�L'CE Gt��Fe�Z f�lA$�'�'� 2�C. This asl�� stos abatement permit is valid beginning 9/ 11 /2006 through 11 : 59 PM on 10/ 10/2006 . Tl�e actual scheduled work dates ai•e from 9/ ll /200E through 10/24/2006 . Approval issued on : 8/28/2006 Amount paid : �275 . 00 Record numher: 53188 Check number: 5980 ��� �34-M (` �> ''� B� C�'� �';1��' P` ; �E,d �� �+ ���.u.}� .�`i. Project �upervisoi° �v�3;�],li1CP : � C3Tic' l �nacio li'Io,zzal�-o Comments : None Cerification No . : 81 � 3 For� the location specified below: Project AIvIS : �ms� » �a �h IZockfledg� Le� nard �', I-� ��-ro►� Floo►°/��fls/�oiler° �3oor�z 107 I2�cltl�d �e I�oad Cerification No . : ? 572 ��1, Project Manager : E��le Cottnty This permit has been issued to : �� �€a �°��� � �' �� �� � �ca � ��Ec €� �� � �� _•�� ���� e �,��� e 4601 Giencoe Street Den��� r, CO �0216 Iss e by : JWA � (� _ . � � I� � � `I".�I. � �� � � � �,`Y' �601 Glencoe Stre�t a Dem°cr, CO 80216 a Tcl : 303 -7Y9-�}901 � Pa.� : 303 -789- l� 53 a Reme<lirrlron Sj�ecialrsl DATE : 09 / 19 / 2006 TC7 : PEFZ1� tT �DI� tN ► S'F"Rr4.TC� C� � COIVIPANY: C; OLC3 �A�0 C1EP.�RTI� EIVT OF H �.�LTH �lND ENVIROI�i � E�1T - FAX NO . : 3C�� . 7 � 2 . CJ27 � �10 . (� F PAGES (( NC � . COVER) : � FROM : CONNIE AL(vIEIDA I �� This facsi��Zile transmission is for the intended recipient or his/her authorized abe��t onl }� . If ��ot� � l� av� ���ceived tliis iacsir7lile in error and you are �ot tl� e intendeci 1•eci ient ' T � � • • p anyq copyin �„ fial•ther ; tf-ansn�� ss � c� n �r disser� izzatron, is sti•ictly prohibited . If you are not the intended �°e� ipient � i �ase � calI �'olorado Envirot�inental inlmediately at � 03 - 7 � 9-4901 , -- � � � �" � Ct !� � C �� i � � �� t� � � � � � � o ����e� ���h �.���i�dg� F �2 �. � m � � � i t / / tit� � f Lf f i r _ L � �' E '�` I� � �TI C � y L"� � �IGO1 ( ilcncoe Street � Dem�er, CO 80216 ^ "1'el : 303-759-4901 > Pa� : 303 -789-4� 53 < Rerne�lrulina Sj�ecralis[ DATE : 09 / 1 4 / 2006 TO : �ERMI`T' �DMII`� 1STRA`CC7R ' COI� PAI� Y : � C7LC� R,�DO C� EPAI�`fli� � l`1T � 1�' F-6 �ALTH rfl.�ID EIi�V [ ROl`�1MEIV�' F�X I� O . : 3 � � , 7 � 2 . 0278 NO . OF PAGES (i �vC �. CovER) : � FR � M : CONNIE ALMEIDA This facsiinile tYa��smissi�n is for the intended recipient or his/l�er autlloriz�d agent only . If you h�ve receiv�d this facsimile in er�•or and vou are not the in�ended recipient anyq copyii7g, furtl�er � i trarlsinission, o� diss�minatian, is strictly prohibited . If you are n�t the intended recipi �nt � lease call Colorado Environn�ental i�nmediately at 303 - 789-4901 . � � C � �t � �f r � � ,I �� � � � C � � � � � � ������ �� �� ������d � � � � � �' r ' � r t t / / / � i � ti�6 S �,� � 1 � r �g � a��o � s� zalvo, � 1 � 3 I�� � �� z� �69� _ � ^--.� �, �.. �k� ,r 'i. \ � A:,.. �' _ � �i �� ,,\ f V .':�'�q� �., �/ f � �'�w... � �� � '� y,��°"`�.\ k, ��-�`� ��.� �g / _' ,�etri�t '- ' . 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" � H �y��¢$ `� £v' y��: i "� f � b�3 . x c'� " . . . ,�''+n-,.ai e =s« � y •�; <:: �g �� $ �! �'�ea�wn�.:: ` � f _ _ �e ��, 4 � � t � r erez , � r� er c_� ► � . �� : � o sz �� � I xp� res � I / 26 { 20t; 7 ±�� ��ii � c� � � � r� tr� � � � � i C � n �� r� 6750 Staplelon Drive South Danver, CO 80216 Phone: (303) 355-2389 Fax' (303) 329 -6268 PLNG6' 1 VVRITT � N ��f�� E � � fVY for �ESPIR�,T � f� S (� MPL�Y� E) � � rvice � at� e p1 / 12/2006 �rrrployee Narrr � e � �rr� plc� y�� � � N : 614- 20- 3237 Perez Hector Acldres � e 550 Alton Way # 4334 b � NVER CC 8023� _ _ __ _ - --- - _ _. . _ _ . _ - - - - _ _ -- — _ _ - - � mpf �yer: Mac � estos Inc Yc� u we �� evaluated in thss aifsce €af yc� � r rra � d � c � ! stat �a � r� l�ted to � � �ar phy � ical c � p� t� ility � tc� vvear a r� spirator. ( � heek ✓ or�e that appli � s ) � There v�ere no abnorr� al findirrgs that �au {d h � mper yaur abil �ty tv perform your job du4i � s �hile �earing a �es�iratar . ❑ The abnormal findings lisfed b� low v�ere n �,t reluted fo vv� � �i �� a 4espira� � r bu4 sho �; !d �� �epo ;ted to y�our pErsonal �hysician for further evalua�ion . � � d aapc� e� the res � lt� o� ths � �v� l �sa�ics � it is r� � � � � r � � r� � h �� y � �s : { � h � ck/ ��. I t �t �� � RR � � A ARE qualified to wear a respira4or . n Have the foliowing rest �ic4ions conc� ming respi �ator us � g � : � ARE t� OT qualified to vvear a r� spiraior. � ' n iC ' � �, i h; r,-� � c �; nr-� N �f° �ar� �or:n �¢ Of {"; i ��h €? r 'Pin. Lj ! (I �iS ��? � � equire fur� h � r 2esting by yu � r �r, v � , � �h } r �i � � � , . o . � ust :, , , � it � � r� . « r, � �4d't � � E..' $� f �c'� �� � € C� { la � ll �`� �� �'i y nc `; n F -� o /+ ic � � .• r ,.� • , n , + r �, ij4 � ; m ,. �r �.. n � r.ac -� � � 3 � r � ,�-� r? �.i �' ?�v; ; � � . Jl/ lVChS G� ( IIIUI lsl. t� t .' IIJ � t �/ � � f �. 4 � G. 6: 1 � '� . i.i 6G �,Ei G' s� . . � h� ust v�e � r Special prescription e ;� e-v�ear nPe� ed Ye acc� mrnadate res �ir�� o ;. ❑ r� ust use an Eve gl � ss cank� � rsicn kit . � tVlay need fo shave Faci � l hair fo a » ure iight seG { � r� ce �tai � ¢Qcv m � sk� , ❑ Need to stop smoking . � Chec � Al� L � hat aPp '� 7he above individual ji9� been examined 4or respiralor fitness in accordance wiih 29 CFR ' 910 134 This limited evaluatio� is spocific 90 respirator use only cmployees should be instructed to repor9 any difficulties in using respirators or change of any physical status to Pheir supervisor or physician . This evaluation included �he Respiratory Questionnaire outlined in 29 CFR 1910 134 . ❑ ?he above individual HAS IYOT been exammed by me for respirator finess. 7he emaloyee 's medical evaluaLon consisted of a review of OSNA's Medical Evaluation Questionnaire in Appendiz C Part A Seclion 2 . In accordance with 29 CFR 1910 . 134 , this Iimiled evalua9ion is specific to respirator use only � mployees should be insfrucYed t report any difficulties in using respirators or change of any physical status Yo their supervisor or physician . 1 his evaluaiion included the Respira4ory Questionnaue outlined in 29 CFR 7910 134 . In accordance with specific OSHA requiremonts, I have informed 4he above named individuai cf the resui4s oi tnis evaivation and of any medical conditions resuifing from exposures tha� may require (urther explanation or 9reatmenl. 1Nhere applicaole, the above named individual has been informed of the increased risk o( Iung cancer a�tributable to �he combined eftecl o( smoking and asbestos , lead andlor o�her chemicai ezposure(s) . Respirators musY be propariy selecred based on the containmenP an� concentralron levels to which the worker w!I! be exposed. Fallure to iollow the use and i4tvnq insPruceion and warninqs /ur proper e contamed on Phe resp�rato+ packaging �nWor Iailure to wear the raspirata durinp afl times ol exposure can rvduce the resp�rator's ePl�cPiveness snd re in sickness r d ath. Wearer must be �ramed �n (h� proper care ol any resp�raPOr Refer ro product Irterature and packap�ng for spec�fic �nlormauon regard�ng fi4 use Wor tr iPar�on -� �I���A ' t ��ANDER , M , D, � mployee's Signature � / _ PLHCP Name (printed) �xpiration Da4e Physician or other Licensed Healthcare Pro(essional To be maintained in the employee's file with a copy 4o the employee r_plhcp_stmt_resp_emplo? ee Page 1 of 1 Print Date: 01 /1 ?J2006 Revision Da4e: 04lO6/2000 � �a {l `''�`r,�\ �' � �C+,\.`. �. �`!Z �`i \�. / t�N;'.h , � S � �A� i�e, _ .�I��- .\\ _ ��on '�� �n�_.. ��,��.g.. . ... . �a^ �T , :;."� . , "rh�. �.:.,.��."Y�^. .,��^`^!",�n ,sR'�,?xa,�... .. ._i�� . :: ,ix'. � T�:'1': ' �„�'^5T ' rs•. r r,,. � ";aN- ^ae t� . fiI �.,�� /`�,.. ` `� .F;� , ea •n•.. . � . r e . . ,.. , . . .ta c � �a:' rtX' � . xx iar� .�. i \ �'r �; • . .de • .�h ! i �3 Y . � Q . � �� r � a. � 4k � � . °@A � � � � 8r � �'� �?!��'p ¢ Pt 4 . e .. � .lf ' / ° �'Y t r'' "'q `� s 1 . —_ ,.. � , �. k'�, ° . 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( � heck �/ o�r � th �t � ppi � �� ) � There we� e no abnormal findings th� at would hamper your ability to perform vour icb duties while �vearinG a �°spira °.or . i The abnormai findincs listed below were nof rei � ted to v��earing a respirato - bu ! should �e reporte� °,c your �ersonai physician for furtner evaluatior . � � s �d � �c� n �f� � r�s � lt� �f rE� is ��� E � �� � on i� e � ;�rry c� � inicn ¢"� �� }ac� �: : ( � � �c �: �i �; LL tf�� at a � e� fy ) '��— AR ` oUalif� e6 'to vve � !' 2 rPSDIfGtO" . � - '—' Nave the fo ! lav✓ ir� g restrictions con :,eming respirat � ' usooe U ARE NOT gualified to Gvear a res � iratar . �—, ;� GUI ?"c iuiin2 " iE � �IrC ri � JOU � ;� i � �' aiC ;� ��\ ' SiC � ai� VJ �� � '"'� US� SJJi.ill a '4�' � � tic �: � � � O ', O` �� � S.% h �' 1`i 'lu : '1C5 .,� v � � CESP� tiY3 ��f �C2" @G � � � E' Cf:� Cc cr 'rr� 2' c ii ^ a ' Q °� ISiOn n �in4r a d�; :O :r ; car 4 ra � '1 " n r-, c '"' c �' t . . , .. O rilli : �. D � 'ai� ; a . � _ .. , � � C ; r� .� n � i ^ _, r_ � n � ., .+ v ,.v .+ tv . I . .. _ . . �I �. St VJE2i .., 't72Cia Df S �.�INilO (1 �, � c �N � � e,.�: Gv :G 2 ., �� I ' ? O�.. o . - � � � i . a .0" . � (�`iust use an � s� e aiass con �� ersicn ki; . � . f a ^ ^ t �` � � �• � .C, i . ., c � i-�. � � �, r. � � ,-. �i'� :� � C — , � ay n c.: � srav ra �� a: r, ai � : ., � � : � �iy � , � seai � � � �e -�a � r� �a „e _ h � . �' iveed ±e stoa smoking . � ; �ck � ,� L �. th� �t � �` €� t � ) �--- �`� ?ne aeove indlwdua� �+ A been examinec tor respirator fi!�ess ir, acco�cance with ?: CFR 1 � 1C ? 3c Tnis I�mnee e��aivauen :s soecif�c :c reso�raio� USE O� �V C �Tp�O�'28£ sheula be ��stroctec te �e�0f; 8 �V OIf7tCU�(IL' S II� L151.^.O !25CCa!p.'; C! CI12 ��78 0' 3�)' `Jri�'SICB: S.HiUS IC tf121" SODE �v " SC ' Cf D`1 �5'Ci2f T7�s eva ; �ztien incluoec tne Respira;en� ��esUOnnairE ounineo in 2G CGR 1910 ', 34 � T'1? 8C�V2 �nONiC'iCH ' � c � . T D?E� EX2f11'r1E^ DY !116 10' f? Sp! �8 :0� fllnBSS I 'lE 2R1DIOvB2 S T°C!G8' 2`.'nIJ2i! On CO ^51S1?�� C� 5 IP�'iBN' O� �S �F+ £ NIE�i:.3 �� Evo:L'21 � p^ �,lu�S1�0���'12RE Ifl f',Dp@�10U: ,�'. P5'; A �BJ(IO^ t . I �, 3CC0'03f1CB WGC ?C ..�, � -�( ? � �i � ? ?C . ihiE li !`, 1'.iBO @e'aiudll0�� IS SR6CII�C [C �E5 �71fa'�O' USE 'Jfll) cTp10)'E°5 SiD��, G nE I ;5; '� �1°� ?cvreoort am difficulties in usmo f° SpP2l0'S C Ch3f1_CE O° Bflv DhvSiCB ' St2tt1E IC 1!lei� SUpB�vi50' Cf C!'�`;SiC�B� ?il�£ 2':8 !t.2liCf1 i�CiUOB� lhB �25Di'2(0')� Qu°SI�O�^Bi�E / �` outlmed in 29 CFR 191G . 134 . � in acco�oance v, ith =_ pecific OSHA recuirements , I have inlorme� the above r,a ^�ec �ndnic �ai o` tne �esuLs o.` lhis e� aluz;! on G �d o` an� meo��a � co�d�ue^,s �eso,ur� irorr expesures tna? may reqwre furtner ezplanalion o� t�eatmen;. Wnere apai �caele the above r�ameo individua; ",as ceen � nio�meo o` �h� m�recse� nsh o i.,no c2ncer attrinutable te tne combinee eftect e` smokino anu asbestos , leao andbr other c7em��a' exposurels ; Respirators must be properly selecfed based on Phe containmen; and concentration levels ro whrch the worke� will be exposetl. Faiiure to toliow (he use anc httino mstrucuon antl v�arnings ior proper use con[arneo on the reso�rator packag�no andior tailure Po wear rne resp�raror ounnc al! 6rnes oi expesure cac reauce the respirator s eRecliveness and resw� �n sicxness or death Wearermust be trainea in the prope� care of ony resp�raror. Reler tc p.oduci lirera�ure anc nacka_qmg ror speciiic �ntormauon reoaromy fi; � use andor limrtations � _.. _ ' W \ / _ — \ �� "� � � � PLH � � ignature � � � mpioyee ' s Signature __ _ . . . .- - — - -- _ _ � -- _ � -- � >; L: . 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Y =� . � _ _ � , y_ _ . � - � � i . ; :Y ��= ° , � �� =-'"` 5 � p� r� e � � r : .. : � : ; ,� � � - - e . - - C� rre # : 2223 �� � �� � � e t 2 j2 � f � �� � ' ��1� � a b � \ Cor� � entra � di � � l � � nt� r� 3350 Pecria Slreet Aurora, CO 8001D Phone: (303) 340-3053 Fax: (303) 340-3862 PLHCP� WRITTEN STATEMENT for RESPIRRTORS ( EMPLOYEE ) Service Datee 05/30I2006 Employee Name : �mployee � SN : _ _ �384 Gaona Donaciano D. Addres� : �739 Santa Fe Ave THORNI°ON CC 80260 Em � toye �: Onyx Speciai Services Inc*(locs ) Yac� �rere evaluated in this affice of your rnedical st�tus relaYed to you � ph�sical capability to 4vear a r�� pirator. ( Check ✓ one that applies } here were no abnormal fmdings that �vould hamper your ability to perform your job du �ies while svearing a resoirator. `�� The abncrmal findings listed below ��ere net reiated to ��� earing a respirator but shcuid be repoR�d to your personal physician for further evaluation . E'sa ed u � o � Yhe resulfs og this evaluatior� i� €s ¢ny opir� ion tha� you : ( � €� � ck ✓ �LL th �t � ppiy' ) a ^ RE qualified to wear a respirator. U Nave the following rEStrictions concerning respirator usage : �--� ARE NGT qualifietl to �vear a respirator . �' Require further .esting by ycur prn� a ;e physici2n ti� " o rr:.�st submit a �n� ntten ;� nort of his/her k� ndings to C � r€ ce �t �ra �ec4icat Cer� fers so th �t a �inal decision on ;; cur abil +: t, to .vear a res �irc �o� can be ma � e . �--� �vtust wear Soecial prescriptian eye-wear r, e-e � �d t� nccornmo��te respirator . � P�lust �� se an Eye glass corversion kit � ���� ay ne�d to shave �' ac�al ?� air ',o assure °,ight seal on ce ,�ta�, n f�ce mas !<s . eea to stop smoking . ` �� Check ✓ _ �eLL � hat app �Y�, i The above indivldual j�; been exam�ned (cr respirater fitness �n accordar.ce wi;h 2S CFR ty i0 134. 7h.is hmi;ec eval,�ation is spec:r:c h� rasFr.�icr ..se only Emplcye° s shcoid be irstructed to report any difficwUes in using respiralcrs or c`.a�ge o( zny pr.ysical status tc their supzrv�soi or piys-o�n 7r, is evaluation ind�.:dec lhe Resei2lo.ry �aest�o�.naire ouUined in 29 CF .'ti ? �� 0 t �4 . ❑ 7he above ir.dividcal I iAS � OT Ce2� examine� by Te far raspirator 5t�ess i he =mp:oyee s rre�'caI evaiu�tion censis(ed of a revfev: of � SHA's PA� dical Eval�a:,cn :.uestionnaire in r',ppenda C Pad A Sec:.�c 2 in acccrda��ce vadh �° C� R t91 � 13t , ;`�is i:m,ted evalcation is sper.i(ic ;o �aspirator use on .y En,p.cyeas sno�ic ;e irstvc:cc to reFon any diff�cWties .n us:r.9 �esa�ra;e:s or cnzng� of any phy;icv: s;a:�s ;c ,���eir supetiisar o� p'�yslc�an. Tr,is eva�cc;�uc inGUded :he F�es;ar �to- y Uuesi�cr.nz�re ,.��.�"ut�ined in 29 C� R 1910 13A � .�.In accordance with speci5c OSH4 requrements, I have informed the abcve namea indrv�oual ef lhe resuits of tn�s eval �alion and o` anq medical c�^.oi;iens resu':hr.e frGm � �xpesures that may reqwre funner explanation or treatment NlYiere apciicabie, :ne at�uve oa ^etl in�ividual nas bzan infermec cf ,tx �r.c�eased ris� c( lan; �'�c'r attr:bu,abie te the cambined ef�ect o! sneking and asbes;os, leaa andlcr ctnzr chemi�i exoosure(sJ. Respirators must be properly selecfed based on the containmani and concanlrafion levels to which the worker •ail! be ea�posed. Faifure �o rollow th,e use and B(ling insvuction and warnrn�s for proper use confa�ned on Ihe iespuaro� packaging and�bi tailum to wea� the respiratorduring afl :imes of ezposure can reauce thc respirarc�'s ¢flecriveness and �asult in sickness or death. Wearer musl be I2ined in fhe p�oper care ol any respiratoi.Relei fo product li[e�alure and packaging lor specilic in/orma (ion regardirq li[, use antl/or /rmilations. k PLHCP gnature � Employee' s Signature � � � g� � � � PLNCP Name ( printed ) Expiration Date � Physician or o;her Licensed Health;,�r2 P�efess�onal 7o be maintained in 4he employee's file with a copy 4o the employee r�ihcp_stmt_resp_employee Paae 1 of 1 Print Date : U513012006 Revision Date: 04/06/2CG0 C � n � enfr� � edi � ai Cer� t� r� 335o Peona Street Aurora, CO 80010 Phone: (3C3) 340-3053 Fax: (303) 340-3BG2 EiViPLOYER AUTHOF2IZP,TION AND It� FO �MP,Tl0 �1 FOR RESPIRATORY EVALUA710N 'iE �1 �' LbYEfZ �° O COME' L�T� TN � FD � LOWIN� Address: 8739 SanYa Fe Ave Employee Name'. Gaona, Donaciano D. THORNTON CO 8C260 Employer: Onyx Special Services Inc'(locs) Employee SSN: 384 Check Ty pe af Respira4or(s) 7o Be Used (Check ✓ ALL that apply ) xten4 of Useage � Check ✓ ALL that apply ) f ❑ Air-purifying (non-powered ) ❑ Air•purifying (powered) ❑ On a daily basis 7otal Hours ❑ Atmosphere supplying Respirator ❑ Occasionally - but not more than twice a week �, Total Hours ❑ Combfnation air-line and SCBA ❑ Rarely - or for Emergency situations only ✓ Total Hours ❑ Continous-Flow Respirator ,Expecied Physical E#or4 Required Check ✓ ALL that appl— y ) -� ❑ Supplied-Air Respirator ❑ l,ight ❑ Moderate ❑ Heavy ❑ Open Circuit SCBA ❑ Closed Circuit SCBA �Xposure to Hazardous Ma4erials �Check ✓ ALL that apply ) ; ❑ Dust h4ask ❑ 1 /2 Face veith Canis:ers ❑ Fuil Face vviih Canisters -- 1�1ake Model Cartridge: ❑ Arsenic ❑ Benzene ❑ Ccke Oven ❑ Cotton Seed I Dust '�� oecial lNork Condiiions � ❑ Cadmium ❑ Formaidenyoe '.(Check '� laLL ThzF Appiy V�lhen Wearinq_ Respirator) � ❑ h�E,hyiere Chlcridc ❑ Lead C� Hich P'.aces ❑ Enc',osed Flaces ❑ Protective Clothing ❑ Texti•.es ❑ Chromium ❑ Temperature Extremes ❑ iAostly Cold ❑ �.4ostiy Hct Other(s): ❑ Gther. �uestionare wiil be : L� HAND CARRiED ❑ MAILED ❑ OTHER cVALUATIGN AUTHORI "LATIOf� BY' $ .gna:u�e ol �r�p.oyer Reoresznlelrve DO 1dCT WRi"CE BELOW THi5 ��NE DO h07 WRITE BELOW TN1S LINE DO N07 WRITE BELOVN 7H15 LIt�E PLNCf� � 1IVRIT'� EN S�'RTE �+I �I�T for E2� � P { R��'QR5 ( E [�lPLOYE �} PHYSICIA�! \NlLL CONiPLETE TNE FOLLOWING � � �'S fi'p'��! rt18�/ COriiclll CO�`IGE(1(!<il !712dICd� i��0;':�a�i�'� dfl� �S I.^ (Ef1Ci'.0 10� :•`�° ��5:�`ic1'�!� E�1r�lOi�B` CC!`t2CI D'1�V � '�� ���1E"„ 3'15 vlllh i)IS20111OCS r��S �;;GAj ��,r.�pe=_e; very sric; limi'c::ons or tne use o` �,nformzUcn o7tai-�ec o :.nr � physical exa-r ,nation ef cuai � e�' � :ii��,d �a�s `%> Ih dn Ci �'�.as. \ii � n`�. m2uun m'.�5: CB CCI'�.ci.ic(1 �if1C �oi ��°.(3 �l16<7 C� Scr2f8:E f'v(r''S if SEDt'::IB � ES ano •^.�si be i e�_ea as 6 f 'fl I�FIII a ,E� Cc.! d tv 'i� . .D� I:,,/!� I'_ �. F ''; O^>- � �aQc'. :5�'c . � fttbtlBGB'S f'.'IEIY �0 �rformed eGCU� f12CdSS�ry f::5i 'IC:i0.1S O.'1 L18 :;Cfk Of Ulli'ES C� d!: Efr��l0� � _` 2 .1� (`., J .oS`c j _...,'..fi(1'.G:c' C(' S r r g^�( � r�':Si 3'.(S 8f1i; SfiicCY P2f5^v^.nCl f'13•; �J° ��.fOf^.lcC. VJhCf� ZOD(Or(�et°_ . �` lhE �:55tlllly' fi1�13:1i fEqC'�fE CC. "r.f��i9Cy' l!°7if11�S[ 6ased upon my findmgs, I have determined that Ihis indis�iduai dCheck ✓ ALL thaf aPP� � B___�_._ P C� orc• :; •es:.r. =:�; �::pr:va. ar� u�, ,e � no',oyee n'�us[ sch.etl�..le a n�caicol exUmir�atron �a'�.th pst ^ C'. � C��L,'.C�� ra ! (� l�PP _— C - , ^lass I - P!u Restr.c:ions on Resorator Usc �— , [] Class II - Some Spec.fic Use E2es;ric'.�ons ❑ To bz useo `or Ernergen�y Resper�se �r Fscape Oniy ! 1 � "n �' -_ ❑ ;:IZSS II1 - Respi �a:or Use is NCT r cRtifffTEL' � Furtner 7eslmg ! E•+aivaucn � s Reouircd 2 ❑ "rC Tes! Reyu:rec Gii Test Perfo�meA Sal!s,aclor!'ry � Fii 7est °erforn',ed Unsa:lsfac:orily it Tesl NOT Performec at � Ci � Ci P'_��E��iC � C � (tf� r�— � Scecia'� G'65C�ipbon eyeweai needCd to 2ccommodate -espira;or � So°cl'al Gres��nol�,on eyevdear r�2ede� ic zccomrc���. te re�p��r� !or - � - a�ai hai: n=eds ;o Ce shaved te ass�re tgnt seal on ccna��.r `ac2 rrask; Physi�iar cr ot.^.er !icensed HeaiP�r,are Pre.essicnal � Tp!o��ee must seer. purthcr ^�eaical evalv�tien by a prn�ale ;.hysi::•.an whe musl sub.r��,t a repc:l to (` nCtC' P9'ifi �'� �1Ss"3� ���..Yi�PYS c! nislhe� fincir.gs to . (Check ✓ A � L ehat apply ) 'j � �7hE� a�cove inc;v�dcal NA.� been exa :nine� `o� r�spirztor (i;n255 in accord2nce w�tn 24 CFR 191 C 13�o Th�s ' im�ted evalcatio� �s soe�ific G� res�irator , u;e only E r, pioyees shculd be �estr�cted to report any diFicu'�Ues in using respirztors or change of any whys,cai sia'us ?e ,nei� superwscr or pr.ys�.cian This evafuat�o� induCed tne Resp�ratcry Q�estionnaire a�C!neC in 2S CfR 1910 134 . [� ?he Fbove mdr:iCuel NP. N T ne?n exacnineci by me tor resr�rator fl.tness. 7he employee�s medical evalua!�on cons�sied ef a :ewe:r of OSHA's t.1cdi�al [valcat,o�� Questionnaire in Appendix C Part A Sec:ion 2 In acccrdance vnih 2° CFR 1910 13A, this lim',ted evalualion is soeci`,c to resp:ra,or use cnly Empioyees v:c�id be �ns�rx�ed !o reper, 2ny d�ttculGes in using resp�rators or cnange of any p'�ys�cal sta��s to Iheir supe^r,sor cr physici2n This e�ia 'u2uon included "�e Respuatory QuesS�nnaire �ntiined in 2° CFR '191C 134 accerdance with specific OSHA requi ;ements. I hsve ir�formed t`�2 above na^�ed Individuai of !he results of this evaluaUon and o` any medical cordd!ens reswung froin �'� ex sures that r'.ay re further explana;ion or trealrnen[ W'',ere appli�Gle. the above named i�div�dua! has be2n rrr�eC of ;ne incre se risk of Iung cancer ait � bl o lhe cy , i ed effect cf smoking and astestos, lead anU/or other chem�.ca! expos�re�s) r��!'" V � _ G� Physici nsNa e �Printed ) �,� ..,�- Pnysiaan' s Signature �.— .3 � v � s�, � Physician ' s License Number ( Optianal in Most States ) Date Exa Expir s O Pa e 1 of 1 Pnnt Date 05I30/2006 r_plhcp_stmt_resp_employer 9 Revision Date : 06/29l19S9 To be maintained in 4he employee's file vrith a copy to ttie employec ConcenQ.ra �1� dical � enters 5ervice i�ate: 05/30/2006 3350 Peoria Street Auraa, CO 80010 Pho�e. (9C3) 340-3053 Pax: (303) 3403H62 Nledicat � urveillance - �sbestos �' a4ient: Gaona , Donaciano D . Job `fitf� ; 5SN : '. -5384 � rr�pinyer: Onyx Special Services 1nc-Denv� t70E3 : 10/ 1411954 Address : 2135 W Nordale Dr �ender: M APPLETON , WI 54914 Nlarital Statu � : M Jab Contact : Matt Hourigan �ddress : 8739 Santa Fe Ave � �Q� � ; �ocal Contact Pho � e : ( 303 ) 371 �7600 �xt. : 7NOFZNTON , CO 80260 � ax: ( 303) 371 -7678 �§ � me Phone : (303) 524-9108 �Fark Phane : (303) 906-2351 Ext . : _ �� C �; ,qSiAN BLACK HISPANIC INDlAN WHITE OTHER The above individaal �r,�as seen on 05/ 30/2006 in accordance vbJith : 29 C � R 1926 . 1101 . 40 CFR 763 . 121 . T@� e folto�r 'sng v+r�s performed : Completion and review of the standardized medical questionnaire and work history with special emphasis direc!ed to the ulmenary , cardiovascular , and gastrointestinal systems perAppendix C in 1 °25 . 1 ^ C1 . I Review of !he emoloyer's description of: !his empioyee' s duties as they refate to the employee' s exposure , the 2mp:oyee s represer,tative er anticipated exposure level , and uerso�� al pro`.ec�ion equ � pment to be uiilized 'oy t�ie erliployee . � � � 8Vl8`'J of ir� sorm2tion from previous medicai ex. am�: r�ations i` BVai� u4JiE . � A physical examination �r� ith emphasie upon the pulmor� ary , c2rciovascular, and gasircin,astlna ! sys�ems . A pulmenary `ur.dion tes4 of forced vitaP cspacity (FVC) 2 ,�d `orced explratorv volume at one secend (FEV 1 ; m ac�oruanc° 4•� ith NibSFI and ATS stanCards . � A chest roentgenogram , pcsterier- anterior, 14x17 inches ( or current f� lm or fil2) �vith in±erpreta!ion in accordance :vith 25 CFR 1926 . �5101 . ((vl) (2) (ii) (C} . f.IOTE : Accordina to 29 CFR 1926 11G1 (Po1j (2 ) (ii ) ( C) , it is up te 4he discrelion of the physician tvne4her or not z chest X- �ay is required . � 7he employee �vas informed by the physician of the results of the exam and of ai� y medfcai conditier�s �haY may resul; firom asbestos exposure including the increased risk of iung cancer aitribu4able to the ccmbined effect of srnoking and asbestos exposure . Unless ctr� erwise noted below , this evalua4( on indlcates that there are no de!ected medical contlitions that v�ould place the employee at an lncreasetl rlsk of mat2ria! health impairmen4 from exposure ta asbestos , and there are nc recommended fimitations on the employee conceming the use of personal protective equipment or respirator . Commenis cr limit�tions (if any) : _ \ „^e..' C�' '�Y�"� �'-r.s ..�i � — � W provider Signature ate Evaluation - Asbestos Nledical S �rveillance Page 1 of 1 Revislon Date: 07/2111 9 9 9 (� 7 gy5 - Zp;K Concen;ra Nea�.�^ Scrne<;s . Inc. An Ri�n,s Resarv ; -- . :; >< I ; - '.i - _ . � , ' I2espirator I'zt '�est Itecord , � �r�i�loyeeo l��t � d�s- C ! .�-�1 °� �-� �9 �c� �v � I9ateo��c?(� � IZ.es ��zz- atvz- Ty� ea ' North "1700 Series � Other� � � �,1SA UltraT���in � �espiz°� tc� �° Srze ; ❑ Small � �ledium ❑ �,arge C: nzz � atraz�� s�-ti4eli c�suid �ff�c� ff-�.spir•� ���° A�to � ❑ Clean Sha�,�en ❑ Facial Scar ❑ 1 — 2 Da�r Beard Grorvth � Dentures Absent ❑ 2 �- Days Beard Gz�o�vth ❑ Glasses � Maustache / Gotee ❑ None ��� f � P� ec; lcs : ' '_�Tegati�;c Pressure C:t.eck (� ?' uss ❑ F�il ' �' csiti��e Pressure Check � �' ass � Fail ��� � T'e� t� : � iz-�itani Szrioke ❑ � itre� ' :'�ble to detect test agent �ui � het�� the use ef respirator ❑ Yes ❑ \' o , Ab ! e ±o t�reathe normally 1�g �' ass ❑ Fait ' Ab1e to breathe deeply� [� Pass ❑ Fail �� Able to turn head side to side 0 Pass ❑ Fail Able to nod head u� & do���n � Pass ❑ Fai ] Able to talk alot�d (count 1_ — 100) � Pass ❑ Pai] � Able to bend ove�- X Pass ❑ Fail ' � rimace [� 1' ass ❑ Fail . Employee Si �natur �____�_ .�.�, Date � ''" 6" C --;� � � - � � ,� i — !`� -��`=� Tester Si ;�natur� : Date� � �� { , 7 l �i , � �� Disclaimer i'Le above respirator fit test �vas perfortned on and by t`�z peron �istcd. "Che results indica;� the performance of thc listed respiratory protective device, as fitted on ihe employee named or. tliis recerd under conC011ed conditions Fit tzstiug as F:erforrneti measures the aoility of thc itspi:atory protective to provide protcc;icn tc the irdividual �e�ted. The Test Conductor ncieher expresses nor im�lies aay guarantec lhat lhis or an identica! respiralory device will provide adequate p;otcciion under condilious ot}ier ilicn thal prescnt when [his test was perforn:ed. [mproper use, maintenance, or application of this or any o!he: respirztory prote;?ive device will reduce or eliminate protection. � � � - . . �,�,oLL=� _ . � , F. �„ �,�� „ � � ,�•;�� t(L1JEIVVIKU1VMh1VlAL� 11V1,./UHAIIVJ'IKUML�IVIJ r�� i�owu � i �FUramicTS2 � � WISE ELSANTO COMPANIES i��ooaviv ��su�t,ms��innon . u.tivaniom eno�acnoN DISYOSA6LC ft PPOII (TIVG CI OTHING ll022 LINPAGE PLACE . : IinNO, Gre, iimD h rnce reo7�ecnoN ST_ LOUIS, MO 63132 uae�riiirvcaaeao�ucrs �Sin� az�55ao . FOZ �3ia� az53��a aeN�rni_arui.i. sr:evicei�en�s �nu INVOICE OflOEROAIE 5/30/Q6 NUM6Efl o CO�OkADO ENVIkONMENTlaL SEkVYCE H COL�FADO ENVIkONMFNTAL SEFVTCE 704549 � ATTN : ACCOUNTS PAYAHIE i WILL CALL ° 460i GLENCOE STfiEET P COMMERCE CITY CO A0022 �pq�TEE T DFNVER CO 80216 r 0 0 CUSTOMEF NO OROER NO. CUSTOMEN PURCHASE OFDER NQ TER SLS # SPEC/AG INSTflUCTlONS '�../ S9i iQ0 6'i30.5/-00 380 DEI 3S6 ST�OCu SHIP VIA: TfFMS: WAREHOUSE' WILL CAL.L kET 30 DAYS 23 . 38R375 EA 5 1 4 33 . I000 33 . 10 3 " RAZOR SCRAFER W/TEL.ESL'U � iANDL_E ::PI2WGS EA 3 3 21 . 4900 64 . 47 'LASTIC SUF'Ek SCOOF SHOVEL 2T dOf7DEN D HANDLE b/flOX _C CS ,:� 5 SI . 97U0 59 . 95 70�URED SWEATSNIF7 kAf,S 2°� Eq =BKiJPAD F'R 6 6 9 , 9500 59 . 70 <iJEE F'AD FS E16042i EA 2 2 '7s30 . 9800 f. , 561 . 96 L02ASH 12G 2HF WET/DhY VAC M d/TOOL.S EDXII EA 2 2 2`i�0 . 00U0 500 . 00 LiDX2I ABATEMENT AIR SAMF'LF UL �OMFLETE �ERIAL 4 ' S �0060105020 h 2 601 �03: �FCI-20 EA 8 8 37 . 4100 299 . 28 �kOUND FAULT INTEkRUFT 20 i1P LOO ' EXTCUkD EA 10 10 35 . i500 3;�1 . 50 LOQ ' EXTENSION COftD i2/3 G GE ]MNIGUARD EA 1 1 f. 195 . 0000 1 , 195 . 00 7MNIf.UARD 4 MANOMETER 3EFIAL :816042i SO811000-3SON EA 5 5 35 . 0000 175 . 00 JERIFIT IkRSTANT SMOKE TUFF KI ( i EA = BOX OF SO TUPES ) �" � � mo e�caaurvn�sr. mnv oE ar*uameo wi.HOUr w rHe eveer oF n oEFnu�r iN vnrmervr rne PR10f1 AIIInONI[n110N nNO n IlEiuflN VOUCHER PUBCrvnSEF WILL �E GHPROEO FOP ALt r�oMOea Faom cus.omeN seemr,e meac�nNOise exaenisesiNCUaaeoiN couemiorv oF aner SIJCiTOTAL : 6 � 753 . 79 n��usEO ia�our°,srs�oi n�?uam n"'isEpne�mnoE AEnso°eiE °aiio°ai�eve��EES�ervo�ar°nEa AL.E3 TAX : 561 . 39 wirwn �ounvsnFrEaoEUVEavonrE aEUrEOExaE�uses. pP{T DUE : 7 � 325 . 18 � SEHVICE GHPOGE OP 1Ya46 PEPIO�IC PAiE �IB¢'e fiNNOAL PEPCENiAGE FATE) WILL BE MPOE ON nNVaaumcewea :woavsraoMimvoicsoere. 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(� 5.1 �.'-�-�m �� �.J �f ��='� �� � �? � �-�"��% �� _- -_-____-___--------- ---------_._.� � _..�rw._ r _.— �___ . _ .. _--- y . --° t'� � °--- ��, �-, � s�% `"�— {?� =--- �'-"` t \ '\� ` � � � ��, `� ��� � ���--- � ¢ : � --------- � � � � � �`�, \\ . \ \ _�_ 6�'�-;��`cF�'�'°�'� 1 � --�.,T .-.�.,� ._ \ \ \ � °�`�� ° �_�` �\ P � ,�., � �����',��'� � � .. ---_ ---- t��'# � � � f ,'f , `� '�, � ��.e� � �� � � ��=� �-��n� �\ ��` '� P---��--- t�"��%�=_ , - �.. � � .� — , -� �__ . � ;�;�;1 � � � } � F� , 's � `s, t � � � � E �;�� �' �� 's � � � � '1�� '_. p'�? `il' . _ .�. d���.e ��= �" � ��4�-� � . o- / �� � � t�-✓�C �='/�+4 �fr��,�s�`d O ��°c� � � � � -��� � `� �� �� ��= �� � � �; �;�' �- �c �...-,�---'— ��� �..__ `��-�- � -- ,,��� �---,-____,-� �� �� ���,��a TOWN OF VA1L CONTRACTOR LICENSE/LIABILITY INSURANCE/WORKERS COMPENSATION REN�WAL FORM LICENSE #: �a� : v - �9- ��� � n�a�: If we do not hear from yau witl�in 30 davs we will dclete you i}om our system. If you wish to be reinstated in the fu[ure it will �e necessary foryou [o resubmit an npplicatiun and pay H�e regular registretion fee. Our files inAicaae yourConcrnctor's Licei�se, Lia6ility Insnrance and/or Workmads Compensntion hes expired and needs ro be renewed Please complete this form nnd remr� it m 'fown of Vail Boilding Depar[men[, 75 South I�'ronmgc Road, Vaiy Colm�ado 81657. A. TowooFVaillicense.................................................................Renewalfeeis: $50 `55� $75 $125 Expired on' B. Liabflitylnsm'a�ceof51,000,000: Expired on: C. Workman's Compensation: If you no longer have employees, you need to sign a le[ter releasing the Town of Vail Prom liability. Expired o¢ D. Master Plumbers License: Please enclose a coov of vour current Stace Plumbers License. Expired on 8. State Elecnieal Liconse: Pleese emlose a conv ofvonr current State Electrical Licevse. Ezpired on: NO RCE REOUIRED BECAOSE FEC HAS BEEN PAID TO THE STATE Pleese renew the above as soo�i ae possible so thnt we cn� ��yda[e ou� wmp�tec flles. It is importem thet you are covered at all times. You cnn have yaor insurnnce campany �nnil a copy of you� i�surence ceniCoete dieeotly [o the Town of Veil, Fax it l0 970-479-2452 or you can drop il off, whichever is morc wnvenient 'fhank you fo[ yoor promp� anention. YOU WILL NOT BE ISSUED A LICENSE OR PERMIT WITHOU'C IT. PL�ASE UPDATE THE FOLLOWING INFORMATION: COMPANYNAME: L0 �0/-a(Io �YlU�12onMU"� I'4I ��'-✓✓� CCS n��aess: �lbo � (� lencoe �4ree (- Denve � , CoLvrnclo �ozlb vnoNen: �303�'789 - '-�901 CONTACTPBRSON: �am� 5 A[«[� �� I �`Iliv� ��.cn [� v If you no longer wish to keep your con[racmrs registrntion wrrent at this time, plcase notify our otTice by phone (479-2139) m� lettcr and your file and liceuso will be pulled. I�:�edcv\FORMS\Permi[s\Building\contractm'_renewal_form.doc 12-27-OS