Date: ___________ _________________________ _____________ 260 Signature of Contractor Official Title
Date: ___________ 916.04 Sample Asbestos Exclusion Letter Prior to acceptance of work and final paym ent, the Contractor shall submit to the Engineer for each building or bridge, on the Contractor’s letterhead, a signed and dated copy of the following letter. The Engineer will be responsible for the distribution of the letter. 270 ASBESTOS EXCLUSION LETTER
____________ Date _____________________________________________________ work address of Engineer for Indiana Department of Transportation ATT: ______________________________ Name, Project Engineer/Supervisor 280 Re: Asbestos Exclusion Location/Description ___________ Contract Number ___________ Bridge Structure Number ___________ Contractor’s Name ___________ Dear Engineer:
I hereby certify that to the best of my knowledge no asbestos containing material 290 was used as a building material in this project. Very truly yours, ________________________________ Signature of Contractor official
________________________________ Title of Contractor official cc: District Bridge Inspection Engineer 300 Environmental Services Director Project File 916.03 1131