FORM 4
EP 1110-1-28
RISK ASSESSMENT DUST WIPE SAMPLING FORM
31 Aug 01
(Single Surface Sampling)
Installation
POC
Housing Group
Street Address
Unit No.
City
State
Dwelling Selection Criteria: All Dwellings
Random
Is surface
Room
Surface
Dimensions
Results
smooth
Surface
Sample
Name
Type (floor,
of Sample
Area
of Lab
and
Substrat
(ft2)
ID#
and
window sill,
Area
Analysis
cleanable
e
(g/ft2)
Number
etc.)
(inches)
?
X
X
X
X
X
X
X
X
X
X
Total number of samples on this page:
Date of sample collection:
Date sent to lab:
B-15
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