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State 1D# <br /> r <br /> SAMPLES, CONT. f <br /> Address sampled tab name Date collected <br /> 39' sou 1=ogsgssc a�I Z� Ia9 <br /> City County ZIP <br /> s7DOMIV SAry a D 00-,V 9S zo 6 <br /> LAB DUST WIPE SAMPLES jpglfl-)Use ASTM acprc;%.'ed wipes only. <br /> XRF <br /> Sample Reading No. Component; _ j Lab Sample Result Result I Result <br /> No. (a cantrmarory) Location t Roo 'Sideia2rNUDJ Component Condition cnsf lD.x (ug) , (tig'!t'J , >_sid.? <br /> ❑Interior ❑Liv:rg roes ❑Bedroom Floor ❑Intact i _ 12'x 12"' ' ❑Yes <br /> t� <br /> FairExterior Ki!cen Ba;hroem ❑Window well <br /> p. <br /> S(� j O:her: (yOCL ❑Window sill ❑Podr j �• S �$' �O <br /> Side: i> B C D ❑Other: I <br /> ❑Intenor ❑ Lie:eg roan ]`Bedroom ❑ Floor ❑;ntact I 12•'x 12;' i ❑ yes j <br /> © Exterior ❑Kitchen ]Bathroom ❑Window well ®Fair `er ®No <br /> D1i �aher: PaRth ®Windowsill ❑Poor ff s�x29�, 13o35054Z <I <� <br /> Side: 6 C D ❑Other: <br /> interior ®Lr:,ng room ]Bedroom ®Floor ]Intact F-12-,12" [3 Yes <br /> ❑ Extenor ' ❑Ki:chen Bathroom ❑Window well ®Fair } C'�er 1 No <br /> S li2 I L)Other: ❑Window sill ❑Poor 30 35�Sg3 <br /> ❑Other: <br /> Side: A B C D <br /> Inlenor I ®Liar,room `]Bedroom ®Floor ❑Intact 12"x 12" Ill ❑ Yes <br /> ❑ Exterior ]Kitsnon 171 Balht,,om ❑Window well Fair _..e. ry C g n I DJo <br /> {3 ❑O:.- ❑Window sill ❑Poor J5�1�9yf 3 <br /> ❑Other. <br /> Side: A n ; D � I <br /> Z] Interior q ,]Lr.`rg rcOr Bedroom ®Floor ❑intact 12" 1 ❑Yes <br /> ❑ Exterior Krc�,en Bathroom ❑Window well Fair _ _. fy RNo <br /> SI(� ]O:t.er ElWindow sill ElPoor C 6 <br /> Sty- ❑Other: <br /> Side, A B D <br /> *Interior ❑Uv.ng riot. J Bedroom (9 Floor ❑intact 2". 12' I ❑Yes <br /> E) Exierp� 0 K'r;c'en J Bathroom ❑Window well ®Fair C::rer, -No <br /> S[S ❑ot.,er. ❑Window silt ❑Poor 13a3Sa5?� �` g <br /> ❑Other: <br /> Side: A 6 00 ! <br /> I ` <br /> ❑Interior I E]Living root:, ❑6edroorn EJFloor Clintact i 12'x 12" ❑Yes <br /> ❑Exterior ❑Hitchen ❑Bathroom ❑Window well ❑Fair _C,.ner. ❑No <br /> 51 Qrr�/� ElO;rer: ❑Window sill ❑poor �3L?3 7 <br /> Side, A B C D ❑Other: <br /> i <br /> OTHER SAMPLES(pottery,imported products,wa!er,etc.) <br /> Description,Location,Comments Lab Sam !e <br /> Sample Pottery:ins;de:ourside tested p <br /> No. ample Wafer first draw sample,kitchen,faucet lest Kit 10# esult Units <br /> ❑Cosmetic ❑Potter I ❑Pos <br /> C1 Home remedy ❑Water Po <br /> ❑Other: 5 <br /> EJ Cosmetic C)Pottery El os <br /> E3 Horne remedy C3 Water C]Neg <br /> ❑Other: <br /> Cl Cosmetic ❑ Pos <br /> ❑Home y Water ❑Neg <br /> [her: <br /> CHAIN OF CUSTODY <br /> Sample <br /> No. Date and Time Relinquished by(Signature) Date and Time Received by(Signature) <br /> ❑A-kt. I I a�I - 1:1 P.m- <br /> Z�IOrl 1t:0064-pm❑A M I I ]A.t.r. <br /> ❑P.m ❑P.t,1. <br /> P.m. I I IM <br /> 3104 Lead Poisoning Folic::-up Form Calilornia Department of Health Services Childhood Lead Poisoning Prevention Branch Page 14 <br />