B24-0396 - 31932 VIA MONTURA09/13/24
CITY OF SAN JUAN CAPISTRANO
RULE 1403 INFORMATION 07/27/21Page 2 of 2
ASBESTOS SURVEY CERTIFICATION (ASC) FORM
REQUIRED PRIOR TO PERMIT ISSUANCE IF THE SURVEY FOUND NO ASBESTOS PRESENT IN THE
PROPOSED WORK AREA OR IF THE SURVEY FOUND “LESS THAN 100 SQUARE FEET” OF ASBESTOS
PRESENT IN THE PROPOSED WORK AREA.
Permit Applicant’s Name: ___________________________________________________________
Permit #: ___________________________________________________________
Job Site Address: ___________________________________________________________
SAN JUAN CAPISTRANO, CA 92675
Does this project include any demolition as defined by SCAQMD?
“Demolition” means the wrecking, or taking out, of any load‐supporting structural member of a facility
or structure and related handling operations, or the intentional burning of any facility. This means that if
you remove as little as one (1) two‐by‐four from a load‐bearing wall, it is considered a demolition.
Other examples of load‐bearing members include foundation, slab, rafters, porch pillars, etc.
CHECK ONLY ONE:
NO
YES – If “yes,” STOP; this form does not apply to you. Please refer to page 1.
WORK AREA:
Describe all materials that would be affected by renovation.
(CHECK ALL THAT APPLY - list all others. Attach additional pages as necessary.)
Acoustic Ceiling
Drywall
Ducting
Fire Proofing
Floor Tiles
(VAT)
Resilient Floor
Covering
Insulation
Linoleum
Mastic
Plaster
Roofing
Stucco
Transite
Cement
TO BE COMPLETED BY A CALIFORNIA STATE CERTIFIED ASBESTOS CONSULTANT:
I, the undersigned, certify that I have personally conducted an asbestos survey of the work area described
above, in full compliance with all applicable state, federal, and local laws and regulations, including South Coast Air
Quality Management District Rule 1403, and found that (CHECK ONE):
no asbestos is present OR less than 100 square feet of asbestos is present.
I certify under penalty of perjury that the foregoing is true and correct to the best of my knowledge, and that I am a
California State Certified Asbestos Consultant in good standing holding the California Department of Industrial
Relations’ Division of Occupational Health and Safety (Cal/OSHA) (DOSH) Asbestos Certification Number below.
California State Certified Asbestos Consultant’s Name:
California State Certified Asbestos Consultant’s Cal/OSHA (DOSH) Asbestos Certification Number:
California State Certified Asbestos Consultant’s Signature:
Date:
** This form may be hand‐delivered to City Hall or emailed to building@sanjuancapistrano.org **
Signatures suspected of being forged or not unique
to this document will be reported to Cal/OSHA.
CAC: Timothy Maskew; CSST: Shaun Drobeck
CAC: 22-7195; CSST: 24-7568
6/10/2024
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 1 of 9
3 WEST ENVIRON MEN TAL, IN C.
949-482-1357
info@3westenviro.com
https://www.3westenviro.com
LIMITED ASBE STOS SAMPLING RE PORT (REV 6-5-24)
31932 V i a Montura
San Juan Capi s trano, CA 92675
Bob b y Ci relli
MAY 28, 2024
In spector
Shaun Drob eck
CSST, CDP H -LST, IAC2 M old Inspector
949-482-1357
info@ 3west env iro .co m
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 2 of 9
TAB LE OF CONTENTS
1: Backgr ound
2: Bulk Sampling
3: Limitatio ns and Attachments
3
5
9
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 3 of 9
Background
3West Env ironmental, I nc. was ret ained by Bobby Cirelli t o co nduct Limited Asbestos Sampling at 31932 Via M o ntura,San Juan Capist rano, CA 92675 due t o suspect ACM being impact ed in t he pro cess of planned renov atio n activ it ies.
The site v isit occurred on 05/28/2024 by t he inspector shown below.
Structure
Hou se
Obvious Structural or Fire
Damage
Partial renovation or repair
Year Built
1978
Square Footage
2,602
Levels
2
Foundation
Sl ab-on -grade
Inspector Certi cations: CAC - Robert Pilzer
This inspection and report wer e performed by Robert Pilzer of 3West Environmental, Inc.
Robert Pilz er 949-482-1357
205 Avenida Del Mar #210
San Clemente, C A 92674
Inspector Certi cations: CAC - Timothy Maskew
This inspection and report wer e performed by Timothy Maskew of 3West Environmental, Inc.
Timothy A Maskew 949-482-1357
205 Avenida Del Mar #210
San Clemente, C A 92674
1: B ACKGR OUND
Informati on
section-MGNhYTk4OTQtMj A4Yi00ODJi LWJjMGMtYj kyMzZl Nzg0ZGYz
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 4 of 9
Inspector Certi cations: CSST - Shaun Drobeck
This inspection and sampling were per for med by Shaun Drobeck under the direction of the CAC(s) listed above.
Shaun Drobeck 949-482-1357
205 Avenida Del Mar #210
San Clemente, C A 92674
Lab Accreditation: NVLAP: EMLAB P&K - Tustin, CA
NVLAP Lab Code: 200757-0
2841 Dow Avenue, Suite 300
Tustin, CA 92780
Dan Shelby
Phone: 623-298-1015
Email: dan.shelby @euro nset.com
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 5 of 9
Asbestos Detected
As a result of t he limited Asbest o s Sampling co nducted, it was found t hat asbest o s:
W as de t e c t e d on t he materials list ed below and att ached oor plan.
The sample lo cat ions list ed are a represent at iv e sampling of t he mat erials in t he structure.
# Of Samples Collected
9 Bul k Samp les
2: BULK SAMPLING
Informati on
section-YTE5OGQyMj UtNWE2Zi00Zj kzLThmOGQtMj BiZTU2YjM4YTNj
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 6 of 9
Dry wall wit h jo int compound o n t hewalls and ceiling t hroughout Tile wit h t hinset in entry way andwest hall bat hroom ACM black mast ic in 1st F loor Westhall bat hroom Wall
ACM black mast ic on det achedmirror in Garage
Areas/Materials Positive for Asbestos
H ighlighted M aterials Test ed or Assumed Posit iv e For Asbestos
Sampl e
ID Mat erial Loca tion Cond/
Fria bl e
Asbestos
Cont e nt
Approx
Qty
1
A,B,C
Drywall w/Joint
Compound
Wa lls/Ceil ing
T hroughout D/F None
De tected 4,000 SF
2
A,B,C
Black
Masti c Bat hroom & Garage #D/N F 10% Chrysoti le
(Masti c)20 SF
3
A,B,C
T il e
w/Thi nse t
E nt rywa y & West
Hal l Bat hroom D/N F None
De tected 200 SF
#ACM Black Mastic obser ved on the 1st Floor West Bathroom Wall. ACM Black Mastic observ ed in the Garage on the Back of detached
mir ror s.
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 7 of 9
Abatement Contractor
Asbest os Con t ain in g Mat e rials we re pre sen t in th e h igh ligh ted m at e rials listed above , a n d m u st be h an dle d
by a Californ ia Lic e n se d Asbe stos Aba tem e n t Con t rac tor.
Materials that test positive at >1% asbestos are r egulated by the EPA, Cal/OSHA, and SCAQMD Rule 1403 or SDAPCD Rule
1206. Materials with results <1% asbestos via PLM are also considered >1% asbestos unless ver i ed to contain <1% asbestos v ia 1,000
Point Count. Materials with r esults >0.1% asbestos are regulated by Cal/OSHA.
Califor nia Code of Regulations
Title 16, Division 8, Article 3. Classi cations
C-22 - Asbestos Abatement Contractor
An asbestos abatement contractor performs abatement, including containment, encapsulation, or removal, and disposal of asbestos
containing constr uction materials, as de ned in Section 6501.8 of the Labor Code, in and on buildings and str uctures. All wor k
per for med and all documentation pr epar ed by an asbestos abatement contractor shall be done in accordance with r egulations and
requir ements of the Division of Occupational Safety and Health (DOSH) of the Department of Industrial Relations.
Oversight & Clearance
It is r ecommended that asbestos abatement oversight be conducted by a State of California Division of Occupational Safety and Health
(DOSH) Cer ti ed Asbestos Consultant (CAC) or Cer ti ed Site Surveillance Technician (CSST) in accordance with all applicable Federal,
State and local regulatory guidelines. The CAC or CSST should be onsite thr oughout the abatement activ ities, including but not limited
to pr epar ation and set up, r emoval activities, nal clean up, and containment tear down.
It is also r ecommended that air sampling be conducted thr oughout the asbestos abatement activities by a CAC or CSST in accordance
with all applicable guidelines. The sampling should include, but not be limited to, ambient air samples collected fr om outside the
containment befor e the star t of and dur ing abatement activities, and nal air clearance testing from inside the containment upon
completion of the abatement activities and passing of a v isual inspection.
It is r ecommended that all air samples be analyzed by an accredited laboratory via Phase Contrast Micr oscopy (PCM), as per National
Institute of Occupational Safety and Health (NIOSH) Method 7400. If nal air clearance samples do not pass (i.e. are not less than 0.01
bers per cubic centimeter s, or f/cc), the wor k area should either be r ecleaned and retested, or the air samples should be reanaly zed
via Transmission Electron Microscopy (TEM), as per NIOSH Method 7402. Upon r eceipt of passing r esults, the containment may be torn
down.
SCA QMD Rule 1403 Procedure 5 Plan
Som e or all of t h e Asbe stos Con tain in g Mate rials sam ple d in t h is re port we re fou n d t o be
dam age d/dist u rbed.
Asbestos black mast ic was observ ed o n t he west hall bathroom wall, and o n det ached mirro rs in t he garage.
Proc e du re 5 Plan s are re qu ire d t o c lean -u p a n y dist u rbe d Asbe st os Con t a in in g Ma teria ls an d a n y associat e d
con te n t s or m at e rials.
In com plian c e wit h SCAQMD R u le 1403, a Procedu re 5 c le an -u p is re qu ire d du e t o dam a ge d ACM m a teria ls. A
Proc e du re 5 cle an -u p pla n m u st be writte n by a CAC an d approve d by th e SCAQMD prior to a n y re n ovat ion ,
abate m e n t , or c le an -u p e ort s. It is re com m e n de d t h at t h e are as n ot be oc c u pied or an y m at e rials or
con te n t s be rem ove d prior to c le an -u p. An addit ion al sit e visit is re com m e n de d. Addit ion a l fe e s apply for
th e c le an -u p pla n .
Sout h Coast AQM D (www.aqmd.gov ) is the local air qualit y m anagem ent district which est ablishes t he guidelines fo rProcedure 5 P lans. P lease click here for more info rmatio n.
3West Env ironmental, I nc. is able t o prepare a P rocedure 5 Plan upo n request .
Testing Protocol: Bulk Sampling Protocol & Analysis
Bulk sampling was in accordance with the AHERA inspection protocol as listed in 40 CFR 763.86.
Samples were analyzed via the EPA recommended method of Polarized Light Microscopy (PLM) in accordance with EPA Test Method 600/R-93/116. Bulk Samples were
analyzed in accordance with the AHERA protocol as listed in 40 CFR 763.87.
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 8 of 9
Testing Protocol: Bulk Limits
ACM ACCM Non-ACCM None Detected
>1%
<1% via PLM
<1% via Point Count
>0.1% via Point Count ≤0.1% via Point Count ND
Because of the limit ations of PLM analy sis, if the Bulk Samples analyzed v ia PLM are found to cont ain <1% asbest os then this is considered ACM.
In order to be classi ed as ACCM these samples would need to be analyzed via "1,000 Point Count" and v eri ed to cont ain <1% asbest os.
Materials t hat t est positive at >1% asbest os are regulated by the EPA, Cal/OSHA, SCAQMD (Rule 1403) or SDAPCD (Rule 1206) and other regulatory agencies. Materials with results at <1% asbest os via PLM are also
regulated unless v eri ed to cont ain <0.1% asbest os via 1,000 Point Count according to the EPA Applicabilit y Determination Index Control Number C112.
31932 Via Montura Bobby C irelli
3West Environmental, Inc.Page 9 of 9
Speci c A reas
This asbest o s sampling was limited to the areas and materials list ed abo v e.
If ot h e r su spe ct Asbest os Con t ain in g Mat e rials (ACM) will be distu rbe d th en t h e se n e e d t o be t e st e d prior t o
bein g distu rbe d or ren ovate d.
Bulk Sampling Limitations
3West Environmental, Inc. provided limited asbestos sampling of agreed upon areas and materials. Some materials may be hidden,
which are not included in this sampling. Further assessment of suspect Asbestos Containing Material (ACM) may be accomplished by a
more compr ehensiv e sur v ey. The samples collected for testing ar e believed to be representative of the area(s) evaluated. However, if
additional suspect Asbestos Containing Materials are found during renovation or remediation activities, these materials should be
sampled by quali ed per sonnel, and analyzed for content prior to further disturbance. Quantities of ACM are approximate. These
number s should be con rmed prior to r emoval, r epair, or remediation activities.
No warr anty , expressed or implied, is made regar ding the professional opinions pr esented in this report. Var iations in site conditions
may exist and conditions not observed or descr ibed in this r eport may be encounter ed during subsequent activities.
Our conclusions, recommendations, and opinions ar e based on an analysis of the obser v ed site conditions. It should be understood
that the conditions of a site can change with time as a result of natural processes or the activities of man at the subject site or nearby
sites. In addition, changes to the applicable laws, regulations, codes, and standards of practice may occur due to gover nment action or
the broadening of knowledge. The ndings of this report may , therefore, be invalidated ov er time, in part or in whole, unless
evaluated again.
Attachments
Lab Resul ts, Chai n of Cu stody,
Fl oor Pl an , NVLAP
3: LIMITATIONS AND ATTACHMENTS
Informati on
section-Yz Y2ZDc4MDQtNTQ5N i00N GUzLThl YTItNj Jl YjFmZjhhYmZh
Approved by:
Approved Signatory
Danny Li
Report for:
Tim Maskew, Certified Asbestos Consultant
3West Environmental, Inc.
205 Avenida Del Mar
#210
San Clemente, CA 92674
Regarding:
Eurofins EPK Built Environment Testing, LLC
Project: 33979-Asbestos; 31932 Via Montura San Juan Capistrano 92675
EML ID: 3657797
All samples were received in acceptable condition unless noted in the Report Comments portion in the body of the report. The results relate only to
the samples as received and tested. The results include an inherent uncertainty of measurement associated with estimating percentages by
polarized light microscopy. Measurement uncertainty data for sample results with >1% asbestos concentration can be provided when requested.
Eurofins EPK Built Environment Testing, LLC ("the Company"), a member of the Eurofins Built Environment Testing group of companies, shall
have no liability to the client or the client's customer with respect to decisions or recommendations made, actions taken or courses of conduct
implemented by either the client or the client's customer as a result of or based upon the Test Results. In no event shall the Company be liable to
the client with respect to the Test Results except for the Company's own willful misconduct or gross negligence nor shall the Company be liable for
incidental or consequential damages or lost profits or revenues to the fullest extent such liability may be disclaimed by law, even if the Company
has been advised of the possibility of such damages, lost profits or lost revenues. In no event shall the Company's liability with respect to the Test
Results exceed the amount paid to the Company by the client therefor.
Dates of Analysis:
Asbestos PLM: 05-29-2024 and 05-30-2024
Service SOPs: Asbestos PLM (EPA 40CFR App E to Sub E of Part 763 & EPA METHOD 600/R-93-116, SOP EM-AS-S-1267)
NVLAP Lab Code 200757-0
EMLab ID: 3657797, Page 1 of 4Eurofins EPK Built Environment Testing, LLC
Eurofins EPK Built Environment Testing, LLC
2841 Dow Avenue, Suite 300, Tustin, CA 92780
(833) 465-5857 www.eurofinsus.com/BuiltClient: 3West Environmental, Inc.
C/O: Tim Maskew, Certified Asbestos Consultant
Re: 33979-Asbestos; 31932 Via Montura San Juan
Capistrano 92675
Date of Sampling: 05-28-2024
Date of Receipt: 05-29-2024
Date of Report: 05-30-2024
ASBESTOS PLM REPORT
Total Samples Submitted:9
Total Samples Analyzed:9
Total Samples with Layer Asbestos Content > 1%:3
Location: 1A, Drywall w/ Joint Compound- Walls/Ceiling Throughout Lab ID-Version‡: 17920764-1
Sample Layers Asbestos Content
Off-White Joint Compound ND
White Drywall with Brown Paper ND
Composite Non-Asbestos Content: 5% Cellulose
2% Glass Fibers
Sample Composite Homogeneity: Moderate
Location: 1B, Drywall w/ Joint Compound- Walls/Ceiling Throughout Lab ID-Version‡: 17920765-1
Sample Layers Asbestos Content
Off-White Joint Compound 1 ND
Cream Tape ND
Off-White Joint Compound 2 ND
White Drywall with Brown Paper ND
Composite Non-Asbestos Content: 15% Cellulose
2% Glass Fibers
Sample Composite Homogeneity: Moderate
Location: 1C, Drywall w/ Joint Compound- Walls/Ceiling Throughout Lab ID-Version‡: 17920766-1
Sample Layers Asbestos Content
Off-White Joint Compound ND
White Drywall with Brown Paper ND
Composite Non-Asbestos Content: 5% Cellulose
2% Glass Fibers
Sample Composite Homogeneity: Moderate
EMLab ID: 3657797, Page 2 of 4Eurofins EPK Built Environment Testing, LLC
The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to
claim product certification, approval, or endorsement by NVLAP, NIST, or any agency of the federal government. The Company reserves the
right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified.
Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When
detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large
amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection
limit and to aid in asbestos identification.
‡ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is
reflected by the value of "x".
Eurofins EPK Built Environment Testing, LLC
2841 Dow Avenue, Suite 300, Tustin, CA 92780
(833) 465-5857 www.eurofinsus.com/BuiltClient: 3West Environmental, Inc.
C/O: Tim Maskew, Certified Asbestos Consultant
Re: 33979-Asbestos; 31932 Via Montura San Juan
Capistrano 92675
Date of Sampling: 05-28-2024
Date of Receipt: 05-29-2024
Date of Report: 05-30-2024
ASBESTOS PLM REPORT
Location: 2A, Black Mastic- West Hall Bathroom Lab ID-Version‡: 17920767-1
Sample Layers Asbestos Content
Black Mastic 10% Chrysotile
Sample Composite Homogeneity: Good
Location: 2B, Black Mastic- West Hall Bathroom Lab ID-Version‡: 17920768-1
Sample Layers Asbestos Content
Black Mastic 10% Chrysotile
Sample Composite Homogeneity: Good
Location: 2C, Black Mastic- West Hall Bathroom Lab ID-Version‡: 17920769-1
Sample Layers Asbestos Content
Black Mastic 10% Chrysotile
Sample Composite Homogeneity: Good
EMLab ID: 3657797, Page 3 of 4Eurofins EPK Built Environment Testing, LLC
The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to
claim product certification, approval, or endorsement by NVLAP, NIST, or any agency of the federal government. The Company reserves the
right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified.
Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When
detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large
amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection
limit and to aid in asbestos identification.
‡ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is
reflected by the value of "x".
Eurofins EPK Built Environment Testing, LLC
2841 Dow Avenue, Suite 300, Tustin, CA 92780
(833) 465-5857 www.eurofinsus.com/BuiltClient: 3West Environmental, Inc.
C/O: Tim Maskew, Certified Asbestos Consultant
Re: 33979-Asbestos; 31932 Via Montura San Juan
Capistrano 92675
Date of Sampling: 05-28-2024
Date of Receipt: 05-29-2024
Date of Report: 05-30-2024
ASBESTOS PLM REPORT
Location: 3A, Tile w/ Thinset- Entryway and West Hall Bathroom Lab ID-Version‡: 17920770-1
Sample Layers Asbestos Content
Beige Tile ND
White Thinset ND
Sample Composite Homogeneity: Moderate
Location: 3B, Tile w/ Thinset- Entryway and West Hall Bathroom Lab ID-Version‡: 17920771-1
Sample Layers Asbestos Content
Beige Tile ND
White Thinset ND
Sample Composite Homogeneity: Moderate
Location: 3C, Tile w/ Thinset- Entryway and West Hall Bathroom Lab ID-Version‡: 17920772-1
Sample Layers Asbestos Content
Beige Tile ND
White Thinset ND
Sample Composite Homogeneity: Moderate
EMLab ID: 3657797, Page 4 of 4Eurofins EPK Built Environment Testing, LLC
The test report shall not be reproduced except in full, without written approval of the laboratory. The report must not be used by the client to
claim product certification, approval, or endorsement by NVLAP, NIST, or any agency of the federal government. The Company reserves the
right to dispose of all samples after a period of thirty (30) days, according to all state and federal guidelines, unless otherwise specified.
Inhomogeneous samples are separated into homogeneous subsamples and analyzed individually. ND means no fibers were detected. When
detected, the minimum detection and reporting limit is less than 1% unless point counting is performed. Floor tile samples may contain large
amounts of interference material and it is recommended that the sample be analyzed by gravimetric point count analysis to lower the detection
limit and to aid in asbestos identification.
‡ A "Version" indicated by -"x" after the Lab ID# with a value greater than 1 indicates a sample with amended data. The revision number is
reflected by the value of "x".
United States Department of Commerce National Institute of Standards and TechnologyCertificate of Accreditation to ISO/IEC 17025:2017NVLAP LAB CODE: 200757-0Eurofins EMLab P&KTustin, CAis accredited by the National Voluntary Laboratory Accreditation Program for specific services, listed on the Scope of Accreditation, for:Asbestos Fiber Analysis2024-01-01 through 2024-12-31Effective DatesFor the National Voluntary Laboratory Accreditation ProgramThis laboratory is accredited in accordance with the recognized International Standard ISO/IEC 17025:2017. This accreditation demonstrates technical competence for a defined scope and the operation of a laboratory quality management system (refer to joint ISO-ILAC-IAF Communique dated January 2009).