DSF (05-0893)oz
U
e BUILDING & SAFETY DEPARTMENT
P.O. Box 1504 (760).777-7012
OFTt�� 7RAR5j(tA2 bTA co FAX (760) 777-7011
LA QUINTA, CALI.0 NIA 92253 INSPECTION REQUESTS (760) 777-7153
C1 AF L'A QUINTA
FIPIANCE DEPT. BUILDING PERMIT
Application Number . . .
05-OOO.Q.0=893 Date
3/16/05
Property Address . . . .
. . 53555 MONROE ST
APN: :
767-210-043- -000000-
Application description
DEMO - SINGLE FAMILY
Property.Zoning . . . .
LOW DENSITY RESIDENTIAL
Application valuation . .
. . 0
Owner
Contractor
NRI CCP I
DEMO UNLIMITED, INC.
C/O NRI CCPI
81750 AVENUE.50
81100 AVENUE 53
INDIO
CA 92201
LA QUINTA CA 92253
(760) 775-5884
WCC: HRH INS
WC: 009421-200.5
01/01/06
CSLB: 473328
05/31/05
CCC:A7C21
Other struct info . ... .
-------------------------------------------------.---------------------------
. NUMBER OF UNITS
2.00
Permit . . . . . . DEMO
PERMIT
Additional desc
Permit Fee . .
45.00 Plan Check Fee
.00
Issue Date . . . .
Valuation . .
0
Qty Unit Charge Per
Extension,
------------------------------------------------------------------------------
BASE FEE
45.00
Special Notes and Comments
DEMO TO BARE GROUND SI14GLE
FAMILY
•RESIDENCE, ABANDON SEPTIC
- BLDG. F/H
Fee summary Charged
Paid". Credited
Due
Permit Fee Total 45.00
.00 .00
45.00
Plan Check Total -
.00 .0.0 .00
.00
Grand Total 45.00
.00 .00
45.00
P.O. Box 1504
VOICE (760) 777-7012
78-495 CALLS TAMPICo FAX (760) 777-701 I
LA QUINTA, CALIFORNIA 92253 INSPECTIONS (760) 777-7153
BUILDING & SAFETY DEPARTMENT
Application Number: Oq - Date:
Applicant: I Architect or Engineer:
Applicant's Mailing Address:
Architect or Engineer's Address:
�Ip
Lic. No.:
tSUILUINV PERMIT DECLARATIONS
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals
Code, and my License is in full force and effect.
License Class License No.
Date Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractors' State License Law for the following reason (Sec. 7031.5, Business and Professions Code: Any
city or county that requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for the permit to file a signed
statement that he or she is licensed pursuant to the provisions of the Contractors' State.License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code) or that he or she is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects
the applicant to a civil penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044,
Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who does the work
himself or herself or through his or her own employees, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is
sold within one year of completion, the owner -builder will have the burden of proving that he or she did not build or improve for the purpose of sale.).
as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors'
State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a contractor(s) licensed pursuant to
the Contractors' State License Law.).
L) I am exempt under Sec. , BA P.C. for this reas
i
WORKERS' COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance•
of the work for which this permit is issued.
I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is
issued. My workers' compensation insurance carrier and policy number are:
Carrier Policy Number
I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'
compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall
forthwith comply with those provisions. I
O,S
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND
CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address N /�
APPLICANT ACKNOWLEDGEMENT
IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on this application.
1. Each person upon whose behalf this application is made, each person at whose request and for whose benefit work is performed under or pursuant to any permit
issued as a result of this application, the owner, and the applicant, each agrees to, and shall, defend, indemnify and hold harmless the City of La Ouinta, its
officers, agents and employees for any act or omission related to the work being performed under or following issuance of this permit.
2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or
cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
construction,
��and-hereby authorize representatives of this county to enter upon the above- en 'oned property for inspection purposes.
ate / fiignal ure (Applicant or Agent):
- ENVIRONMENTAL
KLEAN-UP
Contractors State Licensc #684979 a DOW 0595
NOTICE OF COMPLETION
THIS IS TO CERTIFY" THAT AN ASBESTOS ABATEMENT
PROJECT HAS BEEN COMPLETED IN ACCORDANCE TO
SCAQMD, CAL -OSHA & EPA REGULATIONS AT:
Single Family Residence
Building "F and IH"
.81-470 Avenue 53
jndio, CA
JOB #
EKr7-204-17F/H
Asbestos abatement and disposal of asbestos containing
materials (ACM)
Per survey report number PLM 0629#1806 provided by Scott Morrison & Associates
dated July 8"', 2004.
DATE
October 23:, 2004
JOB. NAME
The Hideaway
Demo Unlimited, Inc.
Mel Curci
PROTECT COMPLETION WITNESSED BY
aM&A4fj San%*
Beverley J. Gran
P.O. Box 285 Mira Loma, CA 91752
Phone (909) 685-5314 Fax (909) 681-5559
Contractors License #684979 DOS14#595
s=,G99189606 01:61 1P00Z/5Z/0Z
SCOTT MORRISON & ASSOCIATES
P.O. Box 55329 31855 Date Palm Drive, Ste. #3-507
Riverside, CA 92517 Cathedral City, CA 92234
(909)624-1665 (760)323-7743
On June 29th, 2004 an asbestos inspection and bulk sampling was conducted at the above project
address. Bulk samples were taken of all suspect asbestos containing building materials (ACBM) at the
request of the client named above. A total of (18) bulk samples were submitted to Carolina
Environmental, Inc. located at: 107 New Edition Court in Cary, NC (NVLAP Code 101768-0 and Cal.
Environ. Lab. Cert. #2483) to estimate the percentage of asbestos by volume and determine the type(s)
present.
Carolina Environmental, Inc. determines percentages and type of asbestos by using EPA approved
method 600/M4-82-020: Interim Method for the Determination of Asbestos in Bulk Samples. Bulk
samples are analyzed by PLM (Polarized Light Microscopy). Asbestos is quantified by using the visual
arena estimation technique and can only determine the approximate percentage of asbestos present.
After a thorough search is conducted and no asbestos .is detected "none detected" will be noted in the
report. The essence of polarized light microscopy is not to emphatically determine that no asbestos is
present, merely that none was detected or, if it was, it was likely to be less than 1.0% of the sample.
When findings reveal less than or close to 1.0% asbestos contained in a sample, further analysis may be
called for on additional samples to confirm or denounce the initial findings. The California Code of
Regulations (CCR 1529) requires bulk sampling be conducted according to the A.H.E.R.A. protocol
provisions of 40 CFR Part 763.86. The A.H.E.R.A. protocol recommends three (3) or more friable
surfacing samples from a homogeneous area be collected and analyzed before any building material is
determined to be non -asbestos containing. Scott Morrison & Associates conducts asbestos inspection
surveys following the A.H.E.R.A. inspection protocol
ASBESTOS INSPECTION BY: Scott Morrison, DOSH #92-0248
BULK SAMPLES ANALYZED BY: Carolina Environmental, Inc., NVLAP #101768-0
(1)
ASBESTOS SURVEY REPORT
Completed On
July 08th, 2004
'
PLM0629#1806
Client: Lori Emery
Emery Land Clearing
P.O. Box 1009
Thermal, CA 92274
-
Project: The Hideaway
CBuilding "F and "H"
81-470 Avenue 53
Indio, CA
(single family home with attached garage and shed)
On June 29th, 2004 an asbestos inspection and bulk sampling was conducted at the above project
address. Bulk samples were taken of all suspect asbestos containing building materials (ACBM) at the
request of the client named above. A total of (18) bulk samples were submitted to Carolina
Environmental, Inc. located at: 107 New Edition Court in Cary, NC (NVLAP Code 101768-0 and Cal.
Environ. Lab. Cert. #2483) to estimate the percentage of asbestos by volume and determine the type(s)
present.
Carolina Environmental, Inc. determines percentages and type of asbestos by using EPA approved
method 600/M4-82-020: Interim Method for the Determination of Asbestos in Bulk Samples. Bulk
samples are analyzed by PLM (Polarized Light Microscopy). Asbestos is quantified by using the visual
arena estimation technique and can only determine the approximate percentage of asbestos present.
After a thorough search is conducted and no asbestos .is detected "none detected" will be noted in the
report. The essence of polarized light microscopy is not to emphatically determine that no asbestos is
present, merely that none was detected or, if it was, it was likely to be less than 1.0% of the sample.
When findings reveal less than or close to 1.0% asbestos contained in a sample, further analysis may be
called for on additional samples to confirm or denounce the initial findings. The California Code of
Regulations (CCR 1529) requires bulk sampling be conducted according to the A.H.E.R.A. protocol
provisions of 40 CFR Part 763.86. The A.H.E.R.A. protocol recommends three (3) or more friable
surfacing samples from a homogeneous area be collected and analyzed before any building material is
determined to be non -asbestos containing. Scott Morrison & Associates conducts asbestos inspection
surveys following the A.H.E.R.A. inspection protocol
ASBESTOS INSPECTION BY: Scott Morrison, DOSH #92-0248
BULK SAMPLES ANALYZED BY: Carolina Environmental, Inc., NVLAP #101768-0
(1)
SCOTT MORRISON & ASSOCIATES
P.O. Box 55329 31855 Date Palm Drive, Ste. #3-507
Riverside, CA 92517 Cathedral City, CA 92234
(909)624-1665 (760)323-7743
The results on the following page(s) indicate that asbestos was detected in 06 of the 18 samples
analyzed.
PLM0629#1806
Samples #HI -61 thru #HI -74 were taken from the single family home labeled "bldg. F". See diagram
Sample #H1-61 Type of material: 12" floor tile- brown (1 rst layer)
Location: floor of east kitchen, diningroom, NW bath
Area: approx. 400 total sq. ft.
Friable:no Results: 3% Chrysotile asbestos
Sample #HI -62
Type of material: floor the mastic- black (2nd layer)
Location: under sample #H1-61
Area: approx. 400 total sq. ft.
Friable:no
Results: 5%Chrysotile asbestos
Sample #HI -63
Type of material: acoustic ceiling- cementitious
Location: interior ceiling of central livingroom
Area: approx. 700 total sq. ft.
Friable:yes
Results: 5% Chrysotile asbestos
Sample #H1-64
Type of material: acoustic ceiling- cementitious
Location: interior ceiling of diningroom
Area: approx. 700 total sq. ft.
Friable:yes
Results: 5% Chrysotile asbestos
Sample #HI -65
Type of material: acoustic ceiling- cementitious
Location: interior ceiling of south-central bedroom
Area: approx. 700 total sq. ft.
Friable:yes
Results: 5% Chrysotile asbestos
Sample #HI -66
Type of material: final coat- white (1 rst layer)
Location: interior south wall of northwest bathroom
Area: throughout interior walls of west rooms
Friable:no
Results: none detected
Sample #HI -67
Type of material: grey coat (2nd layer)
Location: behind sample #HI -66 `
Area: throughout interior walls of west rooms
Friable:no
Results: none detected
(2)
P.O. Box 55329 '
Riverside, CA 92517
(909)624-1665
SCOTT MORRISON & ASSOCIATES
31855 Date Palm Drive, Ste. #3-507
Cathedral City, CA 92234
(760)323-7743
PLM0629#1806
Sample #H1-68 '
Type of material: color coat- green (1 rst layer)
Location: interior north wall of hallway and livingroom
Area: throughout interior walls of east rooms
Friable:no
Results: none detected
Sample #H1-69
Type of material: plaster- grey (2nd layer)
Location: behind sample #HI -68
Area: throughout interior walls of east rooms
Friable:no
Results: none detected
Sample #HI -70A
Type of material: exterior stucco- pink (1 rst layer)
Location: exterior south wall next to garage
Area: throughout exterior south wall only
Friable:no
Results: 2% Chrysotile asbestos
Sample #1-1I-7013
Type of material: exterior stucco- grey (1 rst layer)
Location: exterior south wall next to garage_
Area: throughout exterior south wall
Friable:no
Results: none detected
Sample #HI -71
Type of material: exterior stucco-, grey
Location: exterior north wall
Area: throughout exterior walls .,
Friable:no
Results: none detected
Sample #HI -72
Type of material: tar and gravel (1 rst layer)
Location: exterior south roof of home
Area: throughout exterior roof of home
Friable:no
•. Results: none detected
Sample #HI -73
Type of material: roof felt -(2nd layer)
Location: under sample #11I-72
Area: throughout exterior roof of home
Friable:no
Results: none detected
Sample #H1774
Type of material: roof tar (3rd layer)
Location: under sample #11I-73
Area: throughout exterior roof of home
Friable:no
Results: none detected
(3)
SCOTT MORMON & ASSOCIATES
P.O. Box 55329 31855 Date Palm Drive, Ste. #3-507
Riverside, CA 92517 Cathedral City, CA 92234
(909)624-1665 (760)323-7743
PLM0629#1806
Samples #HI -75 thru #HI -78 were taken from the east 20'x30' shed labeled "bldg. H". See diagram:
Sample #HI -75
Type of material: rolled roofing- grey (1 rst layer)
Location: exterior roof of detached shed
Area: throughout exterior roof of she_ d
Friable:no
Results: none detected
Sample #HI -76
Type of material: roof felt (2nd layer)
Location: under sample #HI -75
Area: throughout exterior roof of shed
Friable:no
Results: none detected
Sample #HI -77
Type of material: stucco- tan (1 rst layer)
Location: exterior west wall of shed
Area: throughout exterior walls of shed
Friable:no
Results: none detected
Sample #HI -78
Type of material: plaster- grey (2nd layer)
Location: behind sample #HI -77 -
Area: throughout exterior walls of shed
Friable:no
Results: none detected
Note:The water well shed just east of 81470 Avenue 53 is metal with a metal roof and a dirt floor.
Therefore, no samples were taken at the time of inspection.
Note: The penetraion mastic around the roof penetrations of building "F" and building "G" are presumed
asbestos containing material (PACM). `
Note: All asbestos containing building material(s) containing greater than 1.0% asbestos by volume or
weight, must be removed by a state certified asbestos abatement contractor prior to any demolition or
renovation of the property.
Inspector
Scott C. Morrison
Certified Asbestos Consultant
DOSH#92-0248
(4)
4ul-06-04 12:48pm From -CAROLINA ENVIRONMENTAL +4811442
T-489 P.02/07 .F-202
LABORATORY REPORT
CAR0UNAlENMNMEWX,,wc.
"1a71NeWl&iWn.CouK.CWy,NC27611 ASBESTOS BULK ANALYSIS'
Phoria: (919) 481.103 . Fm(919)481-1442
Client: Scott Morrison & Associates CEI Lab Code:
A04-4863
31855 Date Palm Dr. Suite, 3-507 Received:
07-02-04
Cathedral City, CA 92234 Analyzed:
07-06-04
Reported:
07-06-04
Project: PLM0629#1806 Analyst:
Sara Harrison
ASBESTOS
CLIENT ID LAS IID HOMOGENEITY DESCRIPTION
HI -61 A276349 , "FLOOR TILE
CHRY 3%
Homogeneous, Brown, Fibrous, Tightly Bound
CHRY 3% SIND 97%
CHRY 5%
HI -62 A276350 MASTIC
Homogeneous, Black, Fibrous, Bound
CHRY 5% MAST 92% CELL A%
HI -63 A276351 ACOUSTIC CEILING
CHRY 5%
Heterogeneous, White, Tan, Fibrous, Loosely Bound
CHRY 5% BIND 70% TALC <1 %
PERI- 20%
PAINT 5%
HI -64 A276352 ACOUSTIC CEILING
CHRY 5%
Heterogeneous, White, Tan, Fibrous, Loosely Bound
CHRY 6% BIND 70% TALC <1 %
PERL 20%
PAINT 5%
HI -65 A276353 ACOUSTIC CEILING
CHRY 5%
Heterogeneous, White, Tan, Pibrous, Loosely Bound
CHRY 5% BIND 70% TALC <1%
PERL 20%
PAINT 5%
H1-66
A276)354 FINAL COAT - ND
Heterogeneous, White; Non-fibrous, Bound ,
RIND an 0/ CELL <1 %
PAINT 10%
Page 1
J0-06-04 12:48am From -CAROLINA ENVIRONMENTAL +4811442 T-489 PAVOT ,'F-202
CAROUNAEAMRONMENTAL,INC, Project: PLM0629#1806
107 New Eaw Cain Cary, NC 27511
Phone: 919A81-1413 Fax: 919.481.1442 -
Lab Code: A04-4863
CLIENT ID L C �p HOMOGENEITY DESCRIPTION ' ASBESTOS
HO -67 A276355
GRAY COAT
Heterogeneous,
Grey, Non-fibrous, Bound
*100%
Pink, Fibrous, Bound
SIND CELL c1 %
COLOR COAT
HI -68 A276356
Heterogeneous,
Green, Non-fibrous, Bound
10%
BIND 90% CELL <1 %
MICA
PAINT 10% '
HI -69 A276357
PLASTER
Heterogeneous,
Grey, Fibrous, Bound
Grey, Non-fibrous, Bound
PLAS 98% CELL 2%
HI -70 A276358A
EXTERIOR STUCCO
Heterogeneous,
Pink, Fibrous, Bound
CHRY 2% BIND
86%
PAINT
10%
MICA
2%
A276358B
EXTERIOR STUCCO
Heterogeneous,
Grey, Non-fibrous, Bound
BIND
97%
MICA
_3%
HI -71 A27f3359
EXTERIOR STUCCO
Heterogeneous,
Grey, Nan -fibrous, Bound
BIND
97%
MICA
3 %
HI -72 A2713360 TAR & GRAVEL
Heterogeneous, Black, Fibrous, Bound
TAR 57 % " FBGL 40%
GRAY 3 % -
ND
MOO
ND
CHRY 2%
ND
M
ND
Page 2
Jul -06-04 11:48pm
From -CAROLINA ENVIRONMENTAL
+4811442
T-488
P.04/07 . F-202.
CARDUNAE fflONMENTAL,INC
Project:
PLM0529#1806
107 New EMon Court
Cary, NC 27511
Phone: 9191181-1413
Fm; 91941-1442
,
Lab Code:
A04.4863
.CLIENT ID
ASBESTOS
LA13ID
HOMOGENEITY, DESCRIPTION
HI -73
A276361
ROOF FELT
ND
Heterogeneous,
Black, Fibrous, Bound
TAR
50'% FBGL
50%-
0%HI-74
H 1-74
ND
ROOF TAR
A276362
Heterogeneous,
Black, Fibrous, Bound
-
•TAR
98% FBGL
2
CELL
<1 %,
HI -75
A276363
ROLLED ROOFING
NO
Heterogeneous,
Grey, Fibrous, Bound
TAR
70%, FBGL
25%
GRAV
5%
H1-76
A270364
BOOF FELT
NO
Heterogeneous,
Black, Fibrous, Bound
TAR
40% CELL
60%
H1-77
NO
A276365 STUCCO
Heterogeneous,
Tan, Fibrous, Bound
BIND
96% CELL
2%
MICA
2%
H1-78
A276366
PLASTER
NO
Heterogeneous,
Grey, Non-fibrous, Bound
PLAS
98% CELL
<1%
MICA
2%
4ul-06-04 12:48pm From -CAROLINA ENVIRONMENTAL +4811442
T-489 P.05/0i .F-202
The following definitions apply
to the abbreviations used in the ASBESTOS BULK
ANALYSIS REPORT:
CHRY = Chrysotile
CELL = Cellulose
DEBR = Debris.
AMOS = Amosite
FBGL = Fibrous Glass
SIND = Binder
CROC = Crocidolite
ORGN = Organics
SILI = Silicates
TREM = Tremolite
SYNT = Synthetics
GRAV = Gravel
ANTH = Anthophyllite
WDLL = Wollastonits
MAST = Mastic
ACTN = Actinolite
CERWL = Ceramic Wool
PL.AS =Plaster
N D = None [)elected
NTREM o Non-Asbeatiform
PERL = Perlite
NANTH = Non-Asbestiform
Tremolite
Anth��phyllite
RUBR =Rubber
CLIENT: Scott Morrison & Associates
PROJECT: PLM0629#1806
CEI LAB CODE: A04-4863
Stereoscopic microscopy and polarized light microscopy coupled with dispersion staining is the analytical technique used
For sample identification. The percentage of each component Is visually estimated by volume_ These results pertain only.
to the samples analyzed. The samples were analyzed as submitted by the client and may not be representative of the larger
material in question. Unless notified in writing to return samples, Carolina Environmental, Inc. will discard all bulk samples
after 30 days.
Many vinyl floor tiles have been manufactured using greater than 1 % asbestos. Often the asbestos was milled to a fiber
size below the detection limit of polarized light microscopy. Therefore, a "None Detected' (ND) reading on vinyl floor tile
Joes not necessarily exclude the presence of asbestos. Transmission electron microscopy provides a more conclusive
'orm of analysis for vinyl floor tiles.
t is certified by the signature below that Carolina Environmental, Inc, is accredited by the National Voluntary Accreditation
grogram (NVLAP) for the analysis of asbestos in bulk materials. The accredited test method is EPA 1600 / M4-82 / 020 for
:he analysis of asbestos in building materials. Procedures described in EPA 1 Boo / R-931 116 have been incorporated
Nhere applicable. The detection limit for the method is 0.1 % (trace amount). Carolina Environmental, Inc,'s NVLAP
accreditation number is #101768-0. This report is not to be used to claim product endorsement by NVLAP or any agency
if the U. S. Government. This report and its contents are only valid when reproduced in fuil. Dust and soil analyses for
asbestos using PLM are not covered under NVLAP accreditation.
ANALYST
REVIEWED BY
Tianbao Poi, Ph.0,
Laboratory Director
End of Repaf�
0
From: Scott Morrison & Associates
I'.O. Boa 55329
Riveraide, CA 92517
(760} 323-7743
Client:. Hv—: R � VE A
Site
Ffm in Results Y
Relinquished By:
HAD OF CUST(}DY Y r r.�s UC
17 1 /LOS wro
To: Carolina Environmental, Inc.
107 New Edition Court
Cary, NC 27511
(919) 451-1413
N VLAP Code 1017684 CA ILAF #240
Person Taking Sam}des• Sc o -TT MR
.zi sir -Ws ii '*42 ~3 iqz-
i ,A .s-3 2A iQ.,j F -,j �iub /o
i3:�fSReceivetlBy: Mp_ Date/Time:1')-OV
(760) 3Z3-7743
Maill�'aa'To; Scott Morrison & Asociates, 31855 Date Pal® Dr., Ste. 0-507, Cathedral City, CA 92234,
From: Scott Morrison & Associates
P.O. Boa 55329
Riverside, CA 92517
(760) 323-7743
Client:_ Avi
Job No. rPLjM0(zq--" j OB
Site
CHAIN OF CUSTODY
A-UP-�f4�
To: Carolina Environmental, Inc.
107 New Edition Court
Cary, NC 27511
(919) 451-1413.
NVL,AP Cate 101768-0 CA FLAP #2483
Penson Taiong Samples:
l " 7 ;�o, c- J �A/4V FN OFF
Sample ;#
Sample Date
Material & Description - -
Lill AA -Pb
Other Information
— 773
06 !22 2MV
Ro-
floajz s RL S.E
YX
L-ks tUQ GaA
L�-_ E_ T____�._ A
•Z -A
Relinquished By: Date/Time: 06 — 30--0 eceived iDatenrune:
MAfflaz To: Scott Morrison & Asociates, 31855 Date Palm Dr., Ste. 0-507, Cathedral City, CA 92234, (760) 323-7743