FORM 2
EP 1110-1-29
LEAD HAZARD CONTROL CLEARANCE DUST SAMPLING FORM 31 Aug 01
(Single-Surface Sampling)
Installation:
POC:
Address:
City:
State:
Housing Group:
Date/Time
Date/Time
Cleanup Completed:
Inspection Initiated:
Component:
Clearance Categories:
Abatement Method:
Surface (floor,
Lab Results
Above
Area (ft2)
(g/ft2)
Room
interior
Smooth?
Action
Sample ID
Sub-
Length
Width
(may be
Name and
window sill,
(yes or
(may be
Units
Level?
#
strate
(inches)
(inches)
complete
Number
window
no)
completed
(yes or
d by lab)
trough, etc.)
by lab)
no)
g/ft 2
g/ft 2
g/ft 2
g/ft 2
g/ft 2
Total number of samples on this page:
Date/Time of sample collection:
Date sent to lab:
(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):
(EPA, State, as applicable)
Signature:
Date:
Figure C-2: Lead Hazard Control Clearance Dust Sampling Form
C-3
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