EP 1110-1-31
31 Aug 01
FORM 8
LEAD-HAZARD IDENTIFICATION RESULTS SUMMARY
Installation
POC
Phone Number:
Building Address or Location
Housing Unit No. (if applicable)
Location of Identified Lead-Based Paint and/or Lead Hazards
Room
Sample Type
Results of
EPA
Basis for Determination
Number
Surface Type (floor,
Sample
(dust, paint,
Lab
Action
of Hazard
Comments
or
window sill, etc.)
ID#
soil)
Analysis
Levels
(e.g., deteriorated paint)
Identifier
Date of sample collection:
Total number of samples collected:
KEY: (1) Room Number or Identifier : must correspond with the unique Unit Number used for each unit as identified in the Risk Assessment Report.
(2) Sample ID # : Must correspond to the unique sample numbers generated during sample collection and submitted in Laboratory Report as part
of the Risk Assessment Report.
(3) Results of Lab Analysis : Report Dust in g/ft; Paint Chips in % by weight and g/g (parts per million (ppm)) and soil in ppm.
(4) EPA Action Levels : Dust: 40 g/ft for floors; and 250 g/ft for window sills; Paint chips 0.5% by weight (5000 g/g (ppm)); and soil: 400
ppm bare soil in play areas; 1200 ppm bare soil, non-play areas.
(5) Basis for Determination of Hazard: Dust exceeds Table A-1 action level for surface evaluated, paint chip exceeds Table A -1 definition for
LBP and is deteriorated, and soil exceeds Table A-1 action levels based on child access and use.
Figure B-9: Lead-Hazard Identification Results Summary Form
B-15
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