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MtWANT rIBtRGLASS ASBESTOS Silica Oust
P7^} Total Dust, Opch Face f | Total Dust, Closco Face f ~Rcspirablc Dust (Cyclone, 1#7 lpm)
1 ' I^Pf BCRCLASS / f -8 >1 CEP MLLIIP 1 1 pvc rws-B r
1 1 OTHER
Asphalt ryMCs Total Dust Other:
a C3 cun
OftCAHICS
Impinccr. Other
Soluton...
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Employee SmokeT QNO QTES Products,Productiox Rate:
WCTTESj \ P I PEl 1 ClCARS|--\
{""^Normal Operations
r Day
f y OownT mc_
) CT r~ tSilica Gcl
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Qg EQUIPMENT MANUFACTURER:
RTV.ZNT: Personal Sample
I 1/ BenO<x f ~ ^ SlPtN f D3 Dupont | ) MSA
OTHER:
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>1/^/MACHINE LOCATION AND NUMBER;
\ 1 Area Sample
2*ZTITLE
LOYEE NUMBER
-23
LOCATICN EMPLOYEES. IN AREA
~-
:
JOB TITLE
Pump Seri al
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Sample JJ Start
No.
H Time
tDust Weight
|| airborne
Fibers/Filter Concentration
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`3-H-
30l-(&6f97-3.75 y/<%3 }ts. m.7r\'23
im
'to .^c Employee wear a respirator? ` f 1 NO .WEN:
YES 'tn SOME Of THE TIME
fta sgo-,,
7*
(Manupacturer, Moocl, Cartridge)
'
UJPIODOSIKETETR: Manufacturer^ Model Setting: 85 oy 90
HEARING PROTECTION USED? a KO t 1 YES
MANUFACTURER TYPE________ _
| 1 Some of the tie...vhen?
--.
Cell
I Mo.
Ha.
__ 9/53..: JziiL 1
Time on
Tine off
Total Tine
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Results X
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Corrected to hour Full day
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CNCNTf-. (Sketchy. Layouts. * Cm.cU1_*t,o on b*c/) t
----------- --7--_______________ __________
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'36
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Signature Sample Oatc:
l WEATHER CONDITIONS: Outside Temp. Wind Direction_______ Wind Velocity^_________
^^^Baromctric Pressure 6"tX>6
I' I Sunny |--| Rain "
I I Partly i--i Snow. *
Cloudy |--| Steamy
1 I Cloudy Poo
Humid
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CTD020502
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CTD020503
fr.CVSHW AL
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A IS
HS D*T A 3hU ;
:,At4PLir:G mliioo
COJUMltMHT
|------- 1 T IQCRCI.A5S
| u/ Total Dust, O^ch Face
fIBCRCLAS S / ^
f \X * 8 P Ctf M^ll i p
CjY Asocstos
f ] Total Dust, Closed Face
1 1 PVC FWS-B
1----- } Silica Oust
I------ 1 Respirable Dust (Cyclone, 1*7 lph)
f~l Other
l i Asphalt FyMcs [ ~T Total Oust f l Other:
C=3 CD cm
Organics
Impincer. Other
Solution...
czrZICT C--\ Silica Gel
Oocs Employee Smoke T QNO |--jYCS
--ICigaretusQ Pipe| 1 Cicarsi S Per Day
Products>Proouction Rate; f^NoRHAL Operations 1 7OownT ime_
/(,'Vjd
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PUMP OR EQUIPMENT MANUFACTURER:
""
DEPARTMENT:
( ] Personal Sample NAME_____ _____________"S
1
~-7
| 3/ Bemo'* |~J DUPONT |
Sipin [ MSA
( ^ OTHtR:
MACHINE LOCATION AND NUMBER:
MODEL
\ 1 Area Sample
LOCATION______________
IE
JOB TITLE
EMPLOYEES. IN AREA
JOB TITLE
>ffLOYEC NUMBER
Control |] Pump
No.
|| Seri al
"Sample Mo.
on\6& o%i\
,Start Time
Stop Time
Total (Hin)
1 j LPM
Volume Liters
1/fe
/t:S IP 2-P 3Mb-
*//>&? //tf /? |
Dust Weight
Fibcrs/Filtzr
4fowl
&\01 o*n |
7fri' ///<{- /fit rA n
nin ^/</b
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1
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AIRBORNE
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CONCCNTRAT1 CUM
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AUDIODOSIMETER: Manufacturer
/ip
Model ___ Setting: 85 or[90.
Dosimeter No.
Cell Ho.
kw
vy-.jz -sg-:,
.
--y
(Manufacturer, Model, Cartridge)
HEARING PROTECTION USED?
MANUFACTURER
cn HO \ I YES
TYPE_________ _
| Some of the tine.. .when?
---.
Time on
Time off
Vt"
Total Time
^iP
Results X
-.121-
Corrected to hour Tull day
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I
CQ-NEMTS: (Sketches, Layouts, fc Calculations on back)
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jURL----
Sample Date:
WEATHER CONDITIONS: Outside Temp. Wind Direction_ Wind Velocity^ Barometric Pressure
Ju&fU2" j2eki IWC&f
I ~ 1 SuxNT |---- 1 I | Partly- i---- 1
Cloudy |--I i ) Cloudy I | /DO
Raim" Snov, " Steamy Humid
CTD020516
CTD020517
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