FORM 3
EP 1110-1-28
DETERIORATED PAINT CHIP SAMPLING FORM
31 Aug 01
(One form for each housing unit, common area, or exterior)
Installation
POC
Housing Group
Street Address
Unit No.
City
State
Dwelling Selection Criteria: All Dwellings
Random
Room Name
Sample
Lab
Component
Units
ID#
Results
and Number
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
g/g (ppm)
Sample all layers of paint, not just deteriorated paint layers.
Total number of samples on this page:
Date assessed:
Date sent to lab:
B-13
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