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State ID# <br /> SAMPLES, CONT. f <br /> Address sampled Lab name Dare collected <br /> 325 S, 1� Pda r y ,es,,,cs Yr d213e ley <br /> City County Zip <br /> S,DWnrJ <br /> LAB DUST WIPE SAMPLES(pg/ll;)UseASTI.I a--proved vripes only. <br /> XRF <br /> Sample Reading No. Component Lab Sample ResuC Result Result <br /> No. (it confirmatory) Location I Roor.�'Srde(=ar HUD) Component Condiricn s!C^5! !D# (µgf , {�tg9t'J , >_srd-? <br /> ❑Interior Lrv:r.g room rt Bedroom �K Floor ❑Intact i 1K 12"x 12' Cl Yes <br /> 9 Exterior j ❑Ki:c`en !I Ba,hreem ❑Window n=_I! ❑Fairj I iT�No <br /> Df I YOther: Po�erT ❑Windowsill ®Poor 13034!-3930 3 i 3[ <br /> Side: IDF C D <br /> L1 Other: I <br /> ®Interior Livirg room 7 Bedroom Floor ❑Intact 12'' i ❑Yes <br /> ❑Exterior ❑Kf;_h=n Bathroom ❑Window well 10 Fair `2r ®No <br /> fl2 I ❑Other: C1 Window sill El Poor !3Q3101131 C ea g <br /> Ij <br /> Side- B C D ❑Other: i I <br /> Interior j 4 Li•:'cg room ] Bedroom ©Floer ❑Intact ' ^ '?"x 12'' i ❑Yes <br /> y�� ❑Exterior j :!]Kitchen 1J Bathroom ❑Window well ❑Fair i C-C, ® No <br /> lilt I ❑Over: ®Window sill Poor f 7 303CM 32 <br /> ❑Other: <br /> Side A B C D <br /> ❑Interior i ❑Li-.icy room rl Bedroom ❑Floor ❑Intact _ tz"x 12'' ❑ Yes <br /> ytr L 8V <br /> I,,,lx ❑Exterior ! _..�.. <br /> F�"[ JN!r� '❑K''.= an !�Bathroom Window well Fair � �No <br /> ]Other: ❑Windowsill ❑Poor i303X3933 C <br /> L)Other <br /> Side, A n � Q <br /> j ❑Interior L.•r3 recur• FloorBedroom IntaCl <br /> I 2"x 12" l ❑ Yes <br /> ❑Exlencr ❑ K;cen _'�Bathrocm ❑Window welt ❑Fair I I� No <br /> I <br /> O;!•.er: ❑Window 5611 ❑Poor I y <br /> ❑Other: j P <br /> Side: A B C D <br /> ❑ Interior i ❑Lrrmg:�cr 'D Bedroom ❑Floor ❑Intact '-2'-1 2' i ❑ Yes <br /> ❑ ZZ I <br /> Exterior I ❑K;!C',en 'J Bathroom ❑Window well ❑Fair _ 0!`.er. I F-1 No <br /> ❑O-..er: ❑Window sill ❑Poor I <br /> Side: A B C D ❑Other: <br /> 1 <br /> El Interior I ❑LivinG g rcom L�Bedroom ❑Floor ❑Intact ,, � t 2'x 12" C)yes <br /> ❑ Exlenor , ❑Kitchen i]Salhroom ❑Window well ❑ Fair I _;C^er: ❑No <br /> ❑O'her ©Window sill ❑Poor j <br /> j ! <br /> Side: A 8 C D ❑Other: I <br /> OTHER SAMPLES(pottery,imported products,vrater,etc.) <br /> p <br /> Sam le Description,Location,Comments Lab$am fe <br /> P Pottery:inside%urside tested <br /> No. Type of Sample water first draw sample,.kitcherr,faucet Test Kir 1D# Result Units <br /> ❑Cosmetic ❑Pottery ❑Pos <br /> Home.remedy Water G✓ i DRRw sf}mt°L��3fPMRoMr, ��r ❑Neg 30 1f <br /> 3,f393 <br /> ❑ <br /> ❑Cosmetic ❑Pottery ❑Pos <br /> ❑Home remedy 0 Water wt�2te 6o Svc RuN ❑Neg <br /> ❑Other: / $ ' C <br /> lYt'koam�t�ftvtGLi 3a3393s <br /> ❑Cosmetic ❑Pottery ❑Pos <br /> ❑Home remedy ❑Water ❑Neg <br /> Q Other: <br /> CHAIN OF CUSTODY <br /> Sample <br /> No. pate and Time Relinquished by(Signature) Date and Time Received by(Signature) <br /> 0441 1 oq C2A M. � 1 I C3A.M.Z'OS ®P.7.S ❑ Pl.i. <br /> 1 1 = ❑P.ht. A.M. <br /> 1 ! ❑P.7., <br /> 3104 Lead Poisoning Fol:ow up Form California f7epattment of Health Services Chtldhc[d Lead Poisoning Prevention Branch Page 14 <br />