EP 1110-1-31
31 Aug 01
FORM 5
RISK ASSESSMENT DUST WIPE SAMPLING
Installation
POC
Housing Group
Street Address
Unit No.
City
State
Dwelling Selection Criteria: All Dwellings
Random
Room
Results of
Surface Type
Is surface
Dimensions of
Sample
Name
Surface
Area
Lab
(floor, window
smooth and
Sample Area
(ft2)
ID#
Substrate
and
Analysis
sill, etc.)
cleanable?
(inches)
(g/ft2)
Number
X
X
X
X
X
X
X
X
X
X
Total number of samples on this page:
Date 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)
Signature
Date
Figure B-6: Risk Assessment Dust Wipe Sampling Form
B-12
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