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SAMPLES Date collected <br /> Address sampled tab name <br /> 3a S. q54 RSR`+- t4 y. zip <br /> — -- County <br /> Coy g.S 7-0G <br /> LAB PAINT CHIP SAMPLES(ppm) :770 <br /> l <br /> _- - Condition pie erHUD) SubstrateiCcforLoeation Flcarrl/Stde perFfUD Gar^ Hent fP Plas!er Inlerior ❑Luing room ;]t3eCrvom DaoCasing ❑Door ❑Fair(slightly del.) ❑Wood Ex for �}Kitchen ❑Bathroom1Yindowsash Q Y1all ❑Poor(very del.) ❑Drywall ❑ 6!etal <br /> ❑other <br /> Other: ❑Window sillColor:D other•Side. A B C D <br /> T Door tasin ❑Door ❑Fair(slightly del.) ❑Wood ❑ Piaster 0 tlo <br /> ❑ interior ❑ Living ro ❑Bedreon g <br /> ❑ekierier ❑Kitchen Bathroom ❑Window sash ❑Mall ❑ Paar(very del.) (1 Drywall 1, <br /> [1 Other <br /> ❑athec ❑Wridow sill <br /> COlor: <br /> ❑Other: <br /> Side A 8 C D ❑Yes <br /> sing [j,Door ❑Fait(siighllydel.) Wood fl Ftaster ❑No <br /> [� <br /> Interior E) ❑Dedroom ca <br /> ar <br /> Living room del []Drywall ❑Metal❑Exterior El Kitchen ❑Salhroom ❑Wind ash El'wan ©Poor(vary (:]Other i <br /> ❑other: ❑Window s' i <br /> d S Color: <br /> Side: A B C D Wood ❑ Plaster Cl Yes <br /> ^� ❑Bedroom ❑Deor casin.a ❑Door Fair(sltghllydel,) Q ❑No <br /> ❑Interior t7 Living room r ve det. 0 Drywall CJ Melal <br /> Exterior ❑Kitchen G Bathroom ❑Window sash ❑ J.all Poo ( ry ) a Other <br /> 0 Other: Q VAndow sill <br /> Colas <br /> •----� El Other: <br /> �- <br /> Sidc A- B C D_ _ = Wool iJ Plaster ❑Yes <br /> —---.. - - Bedroom n D�« �., G Door ❑Fair(slightly ❑ Cl No <br /> [�[nte,ior- (� ing roar' Poor(very dot,) Drywall r t.!elal <br /> ❑aatrimom ❑ dow sash ❑y1ai! Q ry <br /> E] Exterior U K�1r_hvn at <br /> O <br /> ❑Other Other: s l Color: <br /> ❑Other: <br /> Side ATB C C -�-^�� 0 Yes <br /> ❑Ooar ❑Fatr(slightly del.) ❑Wood ❑ ter i <br /> ❑Interior ❑Deorcas; all ❑Rtelat 11 No <br /> ❑Living roam Bedroom Poor vg del.) ❑DryYS <br /> ❑Extennr ❑K,lchen ❑Bathroom ❑Windo+r sasrr Cl Y!a'd ❑ oo ( rY ❑Other i <br /> ❑Ot Q Window s,ll Color: <br /> ❑Olhe,: - <br /> ide: A B C D ❑Yes <br /> nn ❑Fair(slightly del.) ❑Wood ❑P:asler <br /> ❑Int r ❑Living room ❑Sedroom ❑Door casing u Door II ©A18131 ©No <br /> ❑Bathroom d Window sash ❑wall poor(very del.) 0 flrY'va <br /> xletlor ❑Kitchen ❑Other <br /> ❑Other: ❑window SAI <br /> ��- Color. <br /> Q ether: <br /> Sides A a C D <br /> LAB BARE Salt SAMPLES( Pm) Lab Sample Result Result <br /> - tOx (ppm ?std.7 <br /> Sample XRFReading No. HUD <br /> LeCation Side er <br /> No. (it cvnlirmato ❑Yes <br /> []Oripline KPlay area B C D ❑No <br /> 51 CJ Other' {]Yes <br /> ❑Dtiptine ta Play area A B C ❑No <br /> S1 ❑Other: <br /> ❑Yes <br /> ❑Dne plin <br /> C]Play area A B C D Q No <br /> Q Other. ❑Yes- <br /> Pay A a C a El No <br /> ©pripGne C) Y area <br /> ❑Other: <br /> CHAIN OF CUSTODY <br /> N Samplerare and Time Received by(Signature) <br /> o. pate and T+me Relrriquished by(Slpnature) n <br /> / M. <br /> / / (]A.M. � f []P.M <br /> b . <br /> t11{!A� ?i OS 91P.M. <br /> r / ❑A.M. I f IO R II OS ❑P.M. <br /> r r ------ <br /> Cl Pm. ! ©A.M, <br /> f ❑A.M. I f ❑P.M. <br /> I l ©P.M. <br /> ❑AM. <br /> r ❑A.M. ❑P.m, <br /> rhlldheinrl l Pad Poisonin4 Prevention Branch Page 13 <br />