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State ID# <br /> SAMPLES <br /> f Address sampled Lab name Date collected <br /> i 3& 5, e��A fUR i W y- �2FivS i9y✓ /PL 03 I3d I tis <br /> City County Zip <br /> 5 -[PN Sl1 J tau gS"4C <br /> LAB PAINT CHIP SAMPLES(ppm} <br /> i pie Condition Lab Sample Result Rpt <br /> Localion Room/Side(per HUD) Component (per HUD) Substrate/Cor'or !Da (ppm) td.? <br /> interior ❑Living room ❑Bedroom ❑Door casing ❑ Door ❑ Fair(slightly del.) ❑Wood r Plaster ❑Yes <br /> ❑ Ex or ElKitchen ElBathroom ElWindow sash ClWall E) Poor(very dei.) ❑Drywall ❑ Metal ❑No <br /> ❑Other: ❑Window Sill ❑Other <br /> ❑Other: Color: <br /> Side. A B C D <br /> ❑Interior ❑Living ro ❑ Bedroom ❑Door casing ❑Door ❑Fair(slightly del.) ❑Wood ❑ Plastar ❑Yes <br /> ❑Exterior ❑Kitchen Bathroom ❑Window sash ❑Wall ❑Poor(very det.l ❑ Drywall ❑ t'. ❑No <br /> ❑Other. ❑Window sill ❑Other <br /> Side: A B C p ❑Other: Color: <br /> ❑Interior ❑Living room ❑Bedroom r casing ❑Door ❑ Fair(slightly del.) Wood ❑ Piaster ❑Yes <br /> ❑Exterior ❑Kitchen ❑Bathroom ❑Wind ash ❑Wall ❑ Poor(very dot. Cl Drywall ❑ Molal ❑No <br /> ❑Other: ❑Window s: ❑Other <br /> Side: A B C D ❑Other. OS Color: <br /> ❑Interior ❑Living room ❑Bedroom ❑Door casing ❑ Door Fair(slightly det.) ❑Wood ❑ Raster ❑Yes <br /> ❑Exterior ❑Kitchen ❑ Bathroom ❑Window sash ❑Wall >Fair <br /> ery del.) ❑ Drywall ❑ F.letal ❑t40 <br /> ❑Other: ❑Window sill ❑Other <br /> ❑Other. Color: <br /> Side: A B C D <br /> ❑Interior ❑Living room ❑Bedroom ❑ Doci ,ing ❑Loor ightly ❑Wood ❑ Piaster ❑Yes <br /> ❑Exlerior ❑Kitchen ❑Bathroom ❑ clow sash LJViV ❑Poor(very del.) Qrywaf€ ❑;F.tetal ❑No <br /> ❑Other. Window sill er <br /> ❑Other: Color: <br /> Side: A B C D <br /> ❑Interior ❑Living room Bedroom ❑ Door casing ❑Door ❑ Fair(slightly del.) ❑Wood ❑ ter Yes <br /> ❑Exterior ❑Kitchen ❑Bathroom ❑Window sash ❑'Nall ❑ Poo_r{very del,} ❑Drywall ❑ tdetal ❑No <br /> ❑or ❑Window sill ❑Other <br /> i <br /> ❑Other: Color: <br /> ode- A 8 C 0 <br /> ❑Int r ❑Living room ❑Bedroom ❑Door casing ❑Door ❑Fair(slightly der-) ❑Wood L Plaster ❑Yes <br /> xterior ❑Kitchen ❑Bathroom ❑Window sash ❑WaR ❑Poor(very del-} ❑Drywall ❑ Afetal ❑No <br /> ❑Other: ❑Window sill ❑Other <br /> Side: A B C D ❑Other: Color <br /> LAB BARE SOIL SAMPLES(ppm) <br /> Sample XRF Reading No. Lab Sample Result Result <br /> No_ (it confirmatory) Location Side(per HUD) tD# (ppm) >std.? <br /> ❑Dripline Play area QA B C D 0 Yes <br /> s <br /> El Other 303µ3i2 (o D0 ❑No <br /> ❑Dripline Play area A B C ® ❑Yes <br /> SZ ❑Other: Seo ®NO <br /> ❑Dripline ❑Play area A B C D ❑Yes <br /> ❑Other: ❑No <br /> ❑Dripline ❑Play area A B C D F-1 yes <br /> E)Other <br /> El No <br /> CHAIN OF CUSTODY <br /> Sample <br /> No. Date and Time Relinquished by(Signature) Date and Time Received by(Signature) <br /> attAJ 7; EDA.ht- ❑.kM. <br /> ll I0q •057 � I I ❑P.At. - P.M. <br /> I I Q A. <br /> ❑P. I I El PM. <br /> P.M. <br /> I I ❑A,M, I I El P.m. <br /> • El P M. <br /> I I ❑A.M. I I ElP.M. <br /> ❑P.m <br /> 3/04 Lead Poisoning Follow-up Form Carifornia Department of Health Services Childhood Lead Poisoning Prevention Branch Page 13 <br />