FORM 1
EP 1110-1-30
PAINT SAMPLING FORM
31 Aug 01
Installation:
POC:
Address:
City:
State:
Housing Group:
Date/Time
Date/Time
Cleanup Completed:
Inspection Initiated:
Above
Room
Action
Sample
Sub-
Paint
Paint
Test
Name and
Component
Result
Units
Level?
ID #
strate
Color
Condition
Location
Number
(yes or
no)
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 Insp ector (print):
Certification Number(s):
(EPA, State, as applicable)
Signature:
Date:
Figure B-1: Paint Sampling Form
B-8
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