FORM 3
EP 1110-1-29
LEAD HAZARD CONTROL CLEARANCE SOIL SAMPLING FORM
31 Aug 01
(Composite Sampling)
Installation:
POC:
Address:
City:
State:
Housing Group:
Date/Time
Date/Time
Cleanup Completed:
Inspection Initiated:
Sketch a soil sampling plot plan. Indicate sample locations. Collect only the top 1 inch of soil.
High Contact?
Sample
Lab
Location
Bare or Covered
Units
(yes or no)
ID#
Results
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)
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-3: Lead Hazard Control Clearance Soil Sampling Form
C-4
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