EP 1110-1-31
31 Aug 01
FORM 4
DETERIORATED PAINT CHIP SAMPLING
Installation
POC
Housing Group
Street Address
Unit No.
City
State
Dwelling Selection Criteria: All Dwellings
Random
Sample
Lab
Room Name
Component
Units
ID#
Results
and Number
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)
Sample all layers of paint, not just deteriorated paint layers.
Total number of samples on this page:
Date assessed:
Date sent to lab:
Shipped by:
Received by:
(signature)
(signature)
Date results reported:
Analyzed by:
(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)
Signature
Figure B-5: Deteriorated Paint Chip Sampling Form
B-11
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