1432 Washington StFee Paid:
Name:
Address: /
Owner
The above described person is hereby granted a permit to (Move) o (Demolish:
building o feet long, and feet high, now located on
City of Blair, Nebraska, to be finally located on __ ? ' " /Th-=
(Demolition) is to be done on
route to be taken in the removal thereof is as follows: (Here designate the names and
numbers of the streets, alleys, or public grounds to be crossed):
Permit to Move Building or Demolish Structure
Date:
Name:
Address:
c� , and shall take i! °'` ~' G�. The
i
Contractor
The removal thereof shall be under the direction of the Street Commissioner and the
Director of Public Works. The building is to be used for { � °. r c I 1 / �7EL f O L ; purposes.
A statement that all taxes and special assessments on the building to be moved or
demolished and on the land from which it is to be moved or demolished have been fully
paid was received and is attached. A corporate surety bond or two (2)
personal sureties to pay all damages that may be sustained to any property, public or
private, and including curbs, paving, manholes, public utility lines and pipes, by reason of
the moving or demolishing of such building was received on
and is attached.
City Administrator
/1/3z 1 JCfJ hI rr1
. The (Move) or
cc-
0j
UILDING INS ' EC ION
E
❑ CITY OF BLAIR
LOCATION OF INSPECTION:
NAME OF OWNER:
DATE INSPECTION REQUESTED:
TYPE OF INSPECTION REQUESTED:
BUILDING: ❑ FOOTING ❑ DECK FOOTING ❑ FRAMING ❑ DRYWALL ❑ FINAL ❑ PARTIAL
❑ WASHINGTON COUNTY ❑ OTHER
CONTRACTOR
TIME INSPECTION REQUESTED: PERMIT NO:
COMMENTS:
UTILITIES: ❑ SEWER TAP ❑ SEWER ❑ SEPTIC ❑ WATER TAP ❑ REMOTE ❑ WATER SERVICE
❑ PARTIAL
COMMENTS:
ELECTRICAL: ❑ ROUGH IN ❑ FINAL ❑ PERMANENT SERVICE ❑ TEMPORARY SERVICE ❑ PRECONNECT
❑ PARTIAL
COMMENTS:
MECHANICAL: ❑ ROUGH -IN ❑ A/C ❑ FURNACE ❑ RADIANT HEAT ❑ FINAL ❑ PARTIAL
COMMENTS:
PLUMBING: ❑ GROUNDWORK ❑ ROUGH -IN ❑ FINAL ❑ WATER METER INSTALLED ❑ PARTIAL
COMMENTS:
❑ OCCUPANCY GRANTED ❑ CONDITIONAL OCCUPANCY GRANTED
NOTES/REMARKS:
FAXED OPPD\BURT REA
TO CONNECT SERVICE: ON
❑ CONFERENCE ❑ STATUS CHECK
PASSED FAILED
BY
❑ ❑
PASSE IY FAILED
PASSED FAILED
❑ ❑
PASSED FAILED
❑ ❑
PASSED FAILED
❑ ❑
DATE OF INSPECTION MADE: '// s 6(c2 TIME• /�` �C'
A S B E S T O S S U R V E Y R E P O R T
PREPARED FOR:
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
PROJECT LOCATION:
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
Project Date(s): April 19, 2002
Report Date: April 22, 2002
ATC Project ID: 07.22772.0001
ATC Associates Inc.
3712 South 132nd Street
Omaha, NE 68144
LETTER OF TRANSMITTAL i
1.0 SCOPE OF SERVICES 1
2.0 GENERAL SITE CONDITIONS 1
3.0 ASBESTOS SURVEY REPORT 1
3.1 Homogeneous Areas 2
3.2 Sampling Strategy 2
3.3 Suspect Asbestos - Containing Materials 3
3.4 Laboratory Analytical Results 4
4.0 ASSUMPTIONS AND LIMITATIONS 4
APPENDICES
APPENDIX A
APPENDIX B
T A B L E O F C O N T E N T S
LABORATORY ANALYTICAL REPORT
INSPECTOR ACCREDITATIONS
ASSOCIATES INC.
April 22, 2002
Mr. Dirk Roeder
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
Re: Asbestos Survey Report
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
ATC Project Number: 07.22772.0001
ATC Associates Inc. (ATC) is pleased to submit the attached Asbestos Survey
Report conducted at the above - referenced site. This report includes procedures,
methodologies and analytical laboratory results.
ATC appreciates the opportunity to perform these services for Lighthouse
Fellowship, and we look forward to working with you in the future. If you need
any assistance with the implementation of the recommendations contained in this
report, please feel free to give me a call at (402) 697 -9747 and ATC will respond
promptly to your needs.
Sincerely,
ATC ASSOCIATES INC.
Paul Virgillito
Operations Manager
i
Bob Arritt
Director - Asbestos and Lead
3712 South 132n Street
Omaha, Nebraska 68144
www.atc - enviro.com
402.697.9747
Fax 402.697.9170
A S B E S T O S S U R V E Y R E P O R T
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
ATC Project Number: 07.22772.0001
1.0 SCOPE OF SERVICES
The purpose of this project was to perform a NESHAP asbestos survey at the
above referenced property.
ATC provided a representative asbestos survey at the identified building in
accordance with the referenced agreement and as outlined below:
1. Review any existing asbestos reports relating to the site, if available.
2. Survey the site building(s).
3. Identify accessible suspect asbestos containing materials (ACM) in
accordance with the USEPA National Emission Standard for
Hazardous Air Pollutants (NESHAP), (ref.: 40 CFR, Part 61).
4. Collect and analyze bulk samples of suspect materials.
5 (l *tia any asbe8 to g ntai materials and Tecord location
Cn
2.0 GENERAL SITE CONDITIONS
The survey was conducted at the property located at 1432 Washington Street in
Blair, Nebraska. The property contained one (1) fire damaged church. The
building was constructed of wood and concrete block, and was unoccupied at
the time of inspection.
3.0 ASBESTOS SURVEY REPORT
On April 19, 2002, the site located at 1432 Washington Street in Blair, Nebraska
was inspected for asbestos containing building materials by inspector Paul
Virgillito of ATC Associates Inc. Mr. Virgillito has completed the requisite
training for asbestos accreditation as an inspector at a state approved training
provider under TSCA Title II. Mr. Virgillito's AHERA accreditation number is
EDI281108IR and his State of Nebraska Inspector number is 422.
1
The site was visually inspected for the presence of suspect asbestos containing
materials (ACM). Materials that were hidden, not accessible, or when sampled
would damage the integrity of the structure, were not sampled as part of this
survey. Materials visibly identified as non - asbestos (fibrous glass, foam rubber,
wood, etc.) were not sampled. The asbestos survey consisted of three basic steps: 1)
a visual inspection of the proposed site; 2) a determination of homogeneous areas
with suspect surfacing, thermal system insulation, and miscellaneous materials;
and 3) sampling accessible, friable and non - friable, suspect materials.
3.1 Homogeneous Areas
Prior to sampling, homogeneous areas were identified in order to facilitate a
sampling strategy. A homogeneous sampling area can be described as one or more
areas with suspect material similar in appearance and texture that have the same
installation date and function. The actual number of samples collected from each
homogeneous sampling area may vary, dependant upon material type and the
professional judgment of the inspector.
3.2 Sampling Strategy
The sampling strategy incorporated AHERA requirements, quantities of suspect
material, and the inspector's judgment to aid in the identification of suspect
asbestos containing materials. ATC's sampling strategy was to identify and collect
accessible suspect asbestos containing materials (ACM) in accordance with the
USEPA National Emission Standard for Hazardous Air Pollutants (NESHAP),
(ref.: 40 CFR, Part 61). If the analytical results indicated that all the samples
collected per homogeneous area did not contain asbestos, then the homogeneous
area (material) was considered non - asbestos containing. However, if the analytical
results of one or more of the samples collected per homogeneous area indicated
that asbestos was present in quantities greater than one percent asbestos (as defined
by EPA), all of the homogeneous area (material) was treated as an asbestos
containing material regardless of any other analytical results. Materials which were
visually determined to be non - asbestos (i.e. fibrous glass, foam rubber, etc.) by the
accredited inspector were not required to be sampled. Actual collection of a bulk
asbestos sample involves physically removing approximately one square inch (1
in of material and placing it in an airtight sample container. Sample containers
were marked with a unique identification number, which was documented in the
field notes.
2
3.3 Suspect Asbestos - Containing Materials
The following table contains a list of twelve (12) sampled accessible building
materials suspected of containing asbestos:
ITSP.EC
ABLE 1
Exterior Stucco
Interior Stucco
Drywall and Joint Compound
Plaster
Asphalt Shingle
Window Glazing (tan)
1'x1' White Spline Ceiling Tile
2'x2' White Suspended Ceiling Tile
White Patterned Vinyl Sheet Flooring and Brown
Adhesive
White HVAC Duct Tape
12 "x12" Green Floor Tile and Yellow Glue; Black
Mastic
Window Glazing (gray)
The following table is a summary of the suspect asbestos containing materials
that have been determined, through laboratory analysis, to contain asbestos:
White HVAC Duct Tape
l�IATERIAL.,
Exterior of the Building
Lnterior,1° Floor
Throughout Building
Throughout Building
Roof
1st Floor Windows
Basement
Basement
Basement, Kitchen
Basement Windows
LOCATION
Basement, HVAC Ducts
Basement, Restrooms
ASBESTOS :`CONTAININ_G
LOCATION
Basement, HVAC Ducts
SQ. FT. = Square Feet, ND = Non Detect, NA = Not Applicable, LN.FT. = Linear Feet, MY = Mechanical Fittings
3
SAMPLE
NUMBER
1-3
4 -6
7
8 -10
11
12
13
14
15
16
17
18 1
SAMPLE =` APPROX. ASBESTOS
NUMBER: : QUANTITY. CO NTEN T_
16 50 sq.ft. 35 %Q_ 1
3.4 Laboratory Analytical Results
Bulk samples were analyzed by ATC's Omaha, Nebraska laboratory. Polarized
Light Microscope analysis, utilizing dispersion staining techniques (ref.: EPA
Method 600/M4 -82 -020), was performed to determine the asbestos content of the
bulk samples collected at the site. This laboratory is currently a proficient
participant in the American Industrial Hygiene Association (AI TA) Bulk Asbestos
Proficiency Analytical Testing Program; a quality assurance program for polarized
light microscopy analysis. Any material that contains greater than one percent
asbestos is considered an ACM and must be handled according to Occupational
Safety and Health Administration (OSHA), EPA, and all applicable state and local
regulations.
Details of sample analysis are included in Appendix A, which contains a listing
of all analyzed samples, sample locations, and analytical results relating to the
site. Asbestos analytical results are reported as percentage and type. Other
common non - asbestos components may also be noted in the analytical report.
4.0 ASSUMPTIONS AND LIMITATIONS
The results, findings, conclusions, and recommendations expressed in this report
are based solely on conditions noted during the April 19, 2002, ATC inspection of
the site located at 1432 Washington Street in Blair, Nebraska.
ATC did not perform destructive sampling -- it was not within ATC's scope of
work to remove surface materials to investigate portions of the structure or
materials that may lay beneath the surface -- thus, any materials that could not be
visually identified on the surface were not inspected and would not be noted in
this report. ATC's selection of sample locations and frequency of sampling was
based on the inspector's assumption that like materials in the same area are
homogeneous in content.
The report is designed to aid the building owner, architect, construction
manager, general contractor, and potential asbestos abatement contractor in
locating ACM. Under no circumstances is the report to be utilized as a bidding
document or as a project specification document since it does not have all the
components required to serve as an Asbestos Project Design document or an
Abatement Workplan.
4
Our professional services have been performed, our findings obtained, and our
conclusions and recommendations prepared in accordance with customary
principles and practices in the fields of environmental science and engineering.
This statement is in lieu of other statements either expressed or implied. This
report does not warrant against future operations or conditions, nor does it warrant
against operations or conditions present of a type or at a location not investigated.
This report is intended for the sole use of Lighthouse Fellowship, on behalf of Mr.
Dirk Roeder. The scope of services performed in execution of this evaluation may
not be appropriate to satisfy the needs of other users, and use or re -use of this
document or the findings, conclusions, or recommendations is at the risk of said
user.
5
APPENDIX A
LABORATORY ANALYTICAL REPORT
Date:
Client:
ATC Project Number: 07.22772.0001
Lab Client
ID ID
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
A S S O C I A T E S I N C.
April 22, 2002
Lighthouse Fellowship
1432 Washington Street
Blair, NE 68008
Drywall & Joint Compound
(brown)
Plaster (brown)
Plaster (brown)
Plaster (brown)
Asphalt Shingle (silver) and Paper
Felt (black)
BULK SAMPLE ANALYSIS REPORT
Asbestos
Sample Description and Location Layer Type
Exterior Stucco (off white)
Exterior Stucco (off white)
Exterior Stucco (off white)
Interior Stucco (gray)
Interior Stucco (gray)
Interior Stucco (gray)
Date Samples Received:
Project Location:
ATC Lab Batch Number: 02 -554
Other Fibrous
Material
ND
ND
ND Cellulose
ND
ND
ND
ND Cellulose
ND Cellulose
Old Horse Hair
ND Cellulose
ND Cellulose
Old Horse Hair
ND Cellulose
Fiberglass
Cellulose
Mica
Cellulose
Mica
Cellulose
Mica
April 19, 2002
3712 South 132nd Street
Omaha, Nebraska 68144
www.atc - enviro.com
402.697.9747
Fax 402.697.9170
1432 Washington Street
Blair, Nebraska
% Non - Fibrous
Material
100%
Sutcco -like
100%
Sutcco -like
1% 99%
Stucco -like
1% 96%
3%
Stucco -like
1% 97%
2% Stucco -like
2% 96%
2% Stucco -like
15% 85%
Mineral Binders
1% 98%
1% Plaster -Like
1% 99%
Plaster -like
1%
1%
20%
98%
Plaster -like
65%
15% Tar -like
Date:
Client:
ND = None Detected
Trace = <1%
A S S O C I A T E S I N C.
April 22, 2002
BULK SAMPLE ANALYSIS REPORT
Date Samples Received: April 19, 2002
3712 South 132nd Street
Omaha, Nebraska 68144
www.atc- enviro.com
402.697.9747
Fax 402.697.9170
Lighthouse Fellowship Project Location: 1432 Washington Street
1432 Washington Street Blair, Nebraska
Blair, NE 68008
ATC Project Number: 07.22772.0001 ATC Lab Batch Number: 02 -554
Lab Client Asbestos Other Fibrous % Non - Fibrous
ID ID Sample Description and Location Layer Type % Material % Material
12 12 Window Glazing (tan) ND Cellulose 2% 98%
13 13 l'x 1' Spline Ceiling Tile (white) ND Cellulose 100%
14 14 2'x 2' Suspended Ceiling Tile ND Cellulose 100%
(white)
15 15 Vinyl Sheet Flooring (white ND Cellulose 30% 70%
patterned) Binders
Adhesive (brown) ND
16 16 I-1VAC Duct Tape (white) Chrysotile 35% Cellulose 15% 50%
Binders
17 17 12 "x 12" Floor Tile (green) and ND Cellulose 4% 96%
Glue (yellow) Binders
Mastic (black) ND
18 18 . ndow Glazing (gray) ND 100%
Brian Stemmermann, Analyst
Bob Arritt, Manager - Asbestos & Lead Services
• Current Regulations govern asbestos - containing material as material with >1% asbestos.
• Analytical Methods: EPA 600/M4 -82 -020, December 82, EPA 600/R- 93/116, July 93
• Method limitations: Analysis of floor tile and other resinously bound materials by Polarized Light Microscopy may yield false negative results due to method
limitations. In these cases ATC recommends alternative methods of analysis.
• Results shown are results obtained from samples by the method shown and do not constitute approval by use of the or product from which sample was
taken.
ATC is currently a successful participant in the AIHA Bulk Asbestos Proficiency Analytical Testing Program for Laboratories Analyzing Asbestos by Polarized
Light Microscopy.
APPENDIX B
INSPECTOR ACCREDITATIONS
EDUCATIONAL INSTITUTE
for Asbestos Training, Inc.
certifies ffiaf
Aas success/rill; passeofIke course and reru3rer examination mifAaf le
eas/ 70%
coin Flelev i � r efu reioeni r as /� t s!os acc< ec ion unJei sec¢ n
2V6 1.7 f.5G i5 a c 5 (: 64
Course J3'ooi J eer:B
jJuca/ ona!Sinsfifafe
f or uisf esfos 7rasn3nq .9nc_
14S0 Centerpar-A Woad
Bincoln, 50 68512
(402) 4237530
Course Location: ,re aaauatee
3712 Saatd 132.E Street
2, �
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tF
04/17/02 03:57 PM Central Daylight Time The Harry A Koch Co. v Page 1 of 2 #190701
HAK Fax
To: Dirk Roeder
Fax: 334-7272
Subject:
Date: 04/17/2002 03:55 PM
Pages: 2, including cover page
The HarryA Koch Co.
Insurance & Financial Benefits
An As surex Global Partner
From: Danielle Nelson
E-mail: Danielle.Nelsonghakco.com
Phone: 861-7131
Fax: 861-7331
Company:
Address:
04/17/02 03: 57 PH Central Daylight Time The Harry A Koch Co. v Page 2 of 2 #1907L
PRODUCER
INSURED
CO
LTR
THE HARRY A. KOCH CO.
PO BOX 45279
OMAHA NE 68145 -0279
T & R Excavating, Inc.
Weidner Const. Co., Inc.
6139 0 Street
Omaha NE 68127
TYPE OF INSURANCE
A GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR
OWNER'S & CONTRACTOR'S PROT
A AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON -OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
7FICATE F1I3
A EXCESS LIABILITY
X UMBRELLA FORM
OTHER THAN UMBRELLA FORM
A WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL
OTHER
DIRK ROEDER
1 130 PARK ST
BLAIR NE 68008
MCT030600198
BA30600198
CAA30600198
WCA30600198
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS
RE: BLAIR CHURCH DEMOLITION
402 861 -7000
POLICY NUMBER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A ALLIED GROUP INSURANCE
COMPANY
B
COMPANY
C
COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY - IAVE BEEN REDUCED BY PAID CLAIMS.
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM /DD /YY) DATE (MM /DD /YY)
2/01/02 2/01/03
2/01/02 2/01/03
2/01/02 2/01/03
2/01/02 2/01/03
OF ANY ) KIND UPON ,THE
AUTHORIZE ti REPRESENTATIV
COMBINED SINGLE OMIT
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
EL EACH ACCIDENT
I EL DISEASE - POLICY LIMIT
EL DISEASE - EA EMPLOYEE
CO
LIMITS
GENERAL AGGREGATE
PRODUCTS - COMP /OP AGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Any one fire)
MED EXP [Any one person)
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
WC STATU- I I0TH-
X TORY LIMITS ER
I$
I$
$
S
I$
S
NC T1O141
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
1 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
COMPFj(J`k ITS AGENTS OR REPRESENTATIVES.
... DATE IMM /DD/YY)
4/17/02
2000000
2000000
1000000
1000000
100000
5000
S
S
$
S
S
$ 4000000
$
S
LIQ
1000000
4000000
500000
500000
500000