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KOCH ENVIRONMENTAL HEALTH, INC. <br /> PO Box 253, Morrison,Colorado 80465 <br /> Phone 303-932-8484 <br /> PRE-CLEARANCE VISUAL INSPECTION FORM <br /> DATE KEN PROJECT#: LOCATION: WORK AREA: • <br /> - <br /> 11144 05602.-i66 C11 1 M e c4 vg C,lt4 A0"5..5 <br /> TIME: C` `LII� T ENT: CONTRACTOR: Lk/Z KEN REP: j <br /> t 0. 50 F/' FOREMAN: 501.�' _ KoT)'\ <br /> INSPECTION: <br /> ..7.----FIRST INSPECTION _ RE-INSPECTION <br /> ___ FULL CONTAINMENT ✓ SEC ONDARYCONTAINMENT <br /> The Abatement Contractor hereby certifies that the designated representative identified below has v Ily Inspected the war area and ha found <br /> •abatement to be comp)-ted in accordance with ! COPHE Regulation ff8 _ Other cw,je- Jo.•m.... that no <br /> dust/debrls rem. in the work area. <br /> U OR FOREMAN/REP' ' •TINE: nn SIGNATURE: <br /> This work lea has .• found to me= visual clearance criteria for the documents referenced above;clearance sampling may proceed. <br /> _ _ Clearance sampling may not proceed un ' the following corrective actions are taken(describe): <br /> KEM REPRRESEESENTATNE: %� rod-N SIGNATURE: <br /> /„0a'� //' T /„'V <br /> V <br />