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1II <br /> r dt.t 1Ltr_. <br /> rr Y <br /> SAMPLES, CONT. <br /> Address sampled tab name Da:e collected <br /> f <br /> 32r S, /� nog f_. 1*Ve . - o313Q <br /> 1 ay <br /> City Gounly zip <br /> 3J W77 IJ S tilb u.1,v f.5 7w <br /> LAB DUST WE SANT LES(+ ll�g t;)Use ASTM ap;.ro•ied wi as only. <br /> XRF I <br /> Sample Reading No. i Comportert; 1 Cab 5ampre Result Resuk Assulr <br /> lVo. fr+conrxm+vary) Locafion I Poc-.,Sida(,erHUD) Component Condition (y ) ,rt 'll') tsfd,? <br /> ❑inter;ar ; :Q Liv:r�morn ❑Bedroon Floor ]lntacl I $ 12"r 1?e I C?Yes <br /> ®Exte�'mr ❑KiV:en ❑6aLhrccm [3 Window well Q Fair I C:^tr, l_ No <br /> s O:har' FDRL� ❑Window sill ®Poor I <br /> r <br /> S:de: 6 C p ❑Other: f <br /> _ – ®interior Ovy ;morn E,Bedroom 64Floor ❑Intact Z'+2"s ic' I ❑Yes <br /> fl2 n Exterior Q K,:chs•[ 0 SaOrocm ❑Window well 9 Fair ? C.mr d No <br /> I ❑Oaer ❑Window s) ❑Poor <br /> Q Other. I <br /> Side: B C G I I <br /> __...— 0 lnler[gri�Li•,'ng rcor, -'Bedroom El Floor Q Iniaet j � 2"x 1?'� ❑Yes <br /> G Exterior I Q K,:chan ED Bathroom ©Window well ❑Fair I C"er. I ❑No <br /> _ IClOt:•e+. ®Window sin Poor Iu x29"1 r <br /> Side A B C ❑Omer. <br /> U Inleriar ❑Li•:ry^toom Q Bedfaam ❑Floor1 <br /> ❑intact 1 _ t2"x 12'• I Q Yes <br /> pq Br II U E,teiior I Q K-,-nal 1Q 6athrcon C1 Window wail Crn3 Farr r ?':•ar I Q t+o <br /> ❑Window sill 0 PM, � <br /> El <br /> -❑Inlc,or . ._1,L,:r.a<c;r.. HedrOom ❑Floor 0 lntacl i?"r t?` -- - ❑Yes <br /> ❑Extrvgr ❑Krc.en !Ba[sraom C3Ylinoawwell ❑Fair ,rfr i� C3 No <br /> -0 O:".at' ❑Window sill ❑Poor <br /> Other I p <br /> '� , t?'r,:2' ©Yes <br /> ❑1n;enor C7 Lr:ngr�c�r ❑Bedrocm ❑Floor L`�,][Hiatt <br /> ©r,,1e,ry 0 K,'7en .j Batnrocm D 4Vrrtdow well ©Fair Ct`tr I Cl Na <br /> i]p�r,er ❑Window rd Q Poor <br /> ❑Other 1 <br /> Side, A 6 C o <br /> E3Inlenar i Q Living room t j Bedroom (3Floor Q lntacl I :2'x tI" Q Yes <br /> ❑Ederar ❑x;:ct.en iQ Eathtaom ❑Window well❑ �rE--l1 Fair � C^e� ❑No Q;hSr; ❑Window sin LJ Poor ; I <br /> i <br /> j —70—0 Q Other: I I a <br /> Side: A B C 4 <br /> OTHER SAMPLES(ponery.im rled products,Y+e:er•etc. <br /> Descriplion,Location,Comments Lab Sample <br /> SamplB Partery ins+delWlside tested <br /> No. Type of Sample Waren,Rrsrdraw sample,kitchen,faucef Test Kit 10# Aesu!! Unils <br /> Cl Cosmetic ❑Pane'trE) <br /> Pos <br /> ❑Home remedy O Wrier � .FFPS7 DRr�d slJmt°4f BA7)fRaM+, LL7 Neg <br /> ❑Other• <br /> r <br /> ❑Ccsme[io ❑Pahery ❑Pos <br /> ❑Home remedy ®water Wtf tt '6o StC RWNr $ffNkodm ❑Ne2 tPf <br /> ❑ottrer: <br /> Cl Cosmetic Popery ❑Pos [ <br /> ❑Home remedy ❑Water CI Neg <br /> ❑Other: <br /> CHAIN OF CUSTODY <br /> Sample <br /> lva. Oafe and Time RN-nquishadby(Signature) Date and Time Received by(Signature) <br /> � <br /> '7 1 ei C I o Q Q A t.1 <br /> 7,r <br /> I I A 11-1 <br /> ❑AAI. <br /> ❑Ph1. 1 IIvIOf It US P.At <br /> Jr I Cl a►.I. I I 'J A!.s <br /> P t.1. <br /> 3/04 Lead Poisanino Fotto•.s s+p Farm Calilornia Department 01 Health Services t;hifdhcO Lead Poisoning Prevenlion Branch Page 14 <br /> I <br /> t <br />