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Appendix E. Example Building Inspection Form - o'-''-:. BUILDINGS EVALUATION FORM 92 .. U.S. ENVIRONMENTAL PROTECTION AGENCY ' REGION VII - TOXICS AND PESTICIDES SECTION Date: ^' 324 EAST 11TH STREET KANSAS CITY, MISSOURI 64106 Dist. No.:^ Room:_________ __________ Sample Number(s): Building:______________________ Address:. Evaluator:____________________ Phone No.:__________________________ Coated Area: Ceiling Wall(s) Structural Members Above Suspended Ceiling . Pipe Lagging Boiler Insul. Other:______________ _______ Type of Ceiling: Concrete 3 Coat Plaster System Suspended Metal Lath Concrete Joists and Beams Tile Suspended Lay-In Panels Metal Deck Corrugated Steel Steel Beam or Bar Joists Ceiling Height:_ Ceiling Shape: Flat ft. r\ Dome Other (draw): . Folded Plate Barrel Type of Wall (If Coated): Smooth Concrete Rough Concrete Masonry Plasterboard Other: Amount of Friable Material in Area being Evaluated:' _________ sq. ft. Description. ' Fibrous Granular/Cementitious Concrete Like of Coating: (highly friable) (soft) (hard) Thickness:________ lnch(s) Is thickness, uniform: Yes No Coating debris on Floor/Furniture/Work Surfaces: Yes 'No Curtains, expandable partitions, etc. being pulled across coating: Yes No Type of Lighting: Surface.Mounted Suspended Recessed No. of Lights:________ Type of Heating/Cooling Systems: Type of Floor: Concrete Tile Wood Carpet Other:_______ ; What is above the room being evaluated? _____ _______________________' Comments: if: '`Hi ~. :'a ` 5':S -ilS E-l t >*T- . S5c- GLEASON-001123