Figure B-3: Deteriorated Paint Chip Sampling Form

EP 1110-1-28
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FORM 3

EP 1110-1-28

DETERIORATED PAINT CHIP SAMPLING FORM

31 Aug 01

(One form for each housing unit, common area, or exterior)

Shipped by:

Received by:

(signature)

Date results reported:

Analyzed by:

(Note: Attach a Copy of the Chain-of-Custody Form to this Form. See Lab Report for

QA/QC Information.)

NOTES:

Name of Risk Assessor (print)

Certification Number(s)

Signature

Figure B-3: Deteriorated Paint Chip Sampling Form

B-14