EP 1110-1-30
FORM 3
31 Aug 01
ASBESTOS SAMPLING FORM
Installation:
POC:
Address:
City:
State:
Housing Group:
Date Inspected:
Dwelling Selection Protocol:
Sample ID #
HA #
Material Location
Sample Location
Quantiy
Type of ACBM
Friability
Physical
Potential for
Condition
Disturbance
(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-3: Asbestos Sampling Form
B-10
Previous Page
