FORM 2
EP 1110-1-30
LEAD SOIL SAMPLING FORM
31 Aug 01
(Composite Sampling)
Installation:
POC:
Address:
City:
State:
Housing Group:
Date Inspected:
Dwelling Selection Protocol:
Sketch a soil sampling plot plan. Indicate sample locations. Collect only the top 1 inch of soil.
Sample
Lab
High Contact?
Bare or
Location
Units
ID#
Results
(yes or no)
Covered
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)
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 Inspector (print):
Certification Number(s):
(EPA, State, as applicable)
Signature:
Date:
Figure B-2: Lead Soil Sampling Form
B-9
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