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n �t141C 11J11— <br /> SAMPLES, CONT. <br /> Address sampled Lab name Dave Collected <br /> 3�r S, A�,ePoc'f_ Yz_�_., '1k5Nsse '*AI LSM-Ar_ 03130 /Of <br /> City Courtly Zip <br /> LAB DUST WIPE SAMPLES{ 11i g l)Use ASTt,i air^o:ed wipes only, <br /> XRF T� I <br /> j Sample Reading No. Componerl; Lab Sample Resur, Resufr I Resuit <br /> No. Gf canrvmarory) Locarron Room Stde(perh'UD) Component Condition ( ) (Og"n itsid.? <br /> ® , Floor i IQ yes❑Irtener 0 Liv:rg ton L Sedroofn <br /> Extvior 0 Kr 'en E)BatintNm C- <br /> Windowwe3 0 Fair l �«:`t r. I l'7 610 <br /> f ! ao!hv: Pow ❑Wirdowsill Poor ! I <br /> ! S:de: 6) 8 C 0 ❑Other: 3 <br /> ®troenot 4 Li:r'y rovm 8edroonl gFloor o Intact _ r2"x tc' i C1 Yes <br /> �Z n Etted., ? ©K,:_hen ❑BaMrocm ❑Window well 0 Fair '_ `4r ❑No <br /> I ❑0:rer. ❑Window sdl ❑Poor I <br /> []other: <br /> _ Side B C 0 I II <br /> Inlerior Liv rrr rcon ❑Bedroom ❑Floor Q Inlact i _ 7 2"x 12"1 ©Yes <br /> n� ❑E.terior ' C K,!chan 'D Bathroom ©1Yindowwel! Q Fair Il 2 G"er. ii ❑No 1 <br /> V Cl 0+;.e+. ®Window sill Poor I EF 2S*x 2,7 4I <br /> ❑ <br /> Side A B C O!her. <br /> I <br /> U Inleriar ❑Li-.:r.-,,roon rj Bedroom ❑Floor ❑intact I ❑ 12"x 12" ❑Yee ' <br /> 0 E,tenor ! ❑K,cne-n !�Bathrcota __ <br /> []Window wail ❑ratr C::.ar I ']tits <br /> O:her. ❑Window sill Paar <br /> -•. _. ❑Other. <br /> Sick. A C0 <br /> 0 Inlenar D Lr,er;row-, Bedroom ❑Floor intact � 12'=IT. Yes <br /> ❑Exivuor ❑Krci eni Batntoom C]Vitndowwcll ❑Fair _C'rtr i ❑No <br /> J O:!. ❑window sill ❑Poor _ <br /> -- ❑Other <br /> DF7 L,:r•g ❑t3edrocm ❑Floor Q Intact +?'=1 z' O Yes <br /> [IExtwm, U3 K�zi•er+ __J Bathrmrn I D Window well ❑Fair O:. I Cl N;Q <br /> IJ 0!r.er: ❑Window W Cl poor I <br /> f ' <br /> S,ee, A 6 C 0 ©Other: I I <br /> []inienor I❑Living room 0 Bedroom ❑Floor ❑Inlau 77:12" Yes <br /> ❑EKler'Or ❑X';&en ❑Balhr:om 0 Window wall ©Fair I _01n r. 0 No <br /> ❑O!r.yr; Q Window Sill ❑Poor <br /> ❑Other. <br /> Side, A B 7 D <br /> OTHER SA NIP LES(pottery.import a d product s.wa'ar,etc. <br /> Cescriplion,Location,Comnleals Lab Sample <br /> Sample Ppraery Ins+de:Cutside lesled <br /> No. Type of Sample wafer,&V draw sample,kitchen,faucet Test Kit 10# Resuff Units <br /> + 0 Co$M86C ❑PCnery ❑Pot <br /> { o Rome remedy (9 Wrier L✓AIUi FFPST ORA'►-rA"t°C f/BA11f(MIM,Fft4l— ❑Neg <br /> ❑Cosmetc Q Popery ❑PCs <br /> 141, <br /> ❑Home remedy ®Yraler wAr l Gd Svc Runk eeweodm� RstLt!` O Neg <br /> ❑Other; <br /> U Cosmetic ❑Pottery ❑Pos I <br /> ❑Home rem@dy n Wate, ❑Neg <br /> Q Other: <br /> CHAIN OF CUSTOM <br /> Sample <br /> Na- Uafe and Time R?Gnquishedby(SigrtalurP) alr/�afrr and Time Received by(Signature) <br /> ❑A MS <br /> 1 I P1.,. 0 ll laa !l :vs i0. P.>v1 <br /> A f., <br /> 3/04 Lead Poisoning Fellow-up Form Calilornia Department of Heatlh SerOces CNldhc'5d Lead Poisoning Prevention Branch Page 14 <br /> I <br />