b'Sample Paint ChipSAMPLE PAINT CHIPCollection Form - 2D COLLECTION FORMCustomer Name:Address: Telephone: E-mail: (Home)In July 2011, the EPA authorized Certified Renovation InformationRenovators for RRP to collect paint samples andsubmit them to NLLAP recognized laboratories for Fill out all of the following information that is available about the Renovation Site, Firm and Certified Renovator. analysis. Renovation Address: _____________________________________________________ Unit #: ___________ City: _______________________State: _________ Zip code: ____________ Certified Firm Name: ______________________________________________________________________ The RRP Rule does not require any paint testing. Address: ________________________________________________________________________________ However, many provisions of the RRP Rule do not City: _______________ State: _____________Zip code: ____________ Contact #: (____) ____- ______ apply to renovations where a Certified Renovator Email: ____________________________________________________________ determines that the components that will beCertified Renovator Name: ________________________________________________________________ disturbed by the renovation are free of lead-based Date Certified ________/ __________/____________ paint. Certified Renovators must make thisPaint Chip Sample Informationdetermination for each component either by usingan EPA-recognized test kit or by collecting a paint For each sample collected, fill out all of the following information Sample Identifier: ___________________________chip sample and submitting it to an NLLAPSample Collector Name: ___________________________________________________________________ (National Lead Laboratory Accreditation Program)Sampling Location: ________________________________________________________________________ for analysis. Certified Renovators should use this Sampling site description: ___________________________________ Date of Collection: ____/_____/_____ 2type of form as they collect and submit paint chip Sample Dimensions (cm): _______________________Calculate Sample Areacm_______________________ samples for this purpose. NLLAP-recognized entity and location: _______________________________________________________ Paint Chip Sample Collection Form Page__ of __Submission date: ____/_____/_____ Results: _______________________ Result Date: ____/_____/_____ Once the results are received, they can be recorded EPA Certified Renovator:Certification No.on the Lead Test Record form. As with all forms,2010-2014 AWDI, LLC.- All Rights Reserved. May be copied without changes for personal use but not resold in any form.these records must be retained for 3 years.Sampling Chain of Custody Form - 2FSince the EPA allows CertifiedRenovators to collect paintChain of Custody Record Page ofchip samples from paintedTo Be Used For All Types Of AnalysisCustomer CodeRequired Turn Aroundcomponents that will beBILLED TO PROJECT INFORMATION ANALYSIS REQUIRED Time4 HourName: Sampled By: Date Sampled: 8 HourYamate Level IIMold - Viable / Non Viable Air / BulkMetals (TCLP, CAM17, STLC) PCM Asbestos Air - NIOSH 7400PLM Asbestos Bulk- 40 CFR 763Lead (Wipes, Air, Paint, Soil)TEM (Air/Bulk)Drinking Water Asbestos/Leaddisturbed by a renovation24 HourAddress: Project Name: Job #: 2 Days/48 Hour3 Days/72 Hourand submit those samplesCity: Site Address: 5+ Days/120 Hour - AHERA/State: Zip: City, State, Zip: DISPOSALto an NLLAP- recognizedPhone No: Site Contact: Customerentity for analysis; thereFax No: Phone No: Fax No: MACSCell No: Comments: OTHERare added records thatEmail: Samples Preserved:Yes/ No Received Cold: Yes/ No (Explain)TIME TIME TOTAL FLOW RATES Comments /Areaneed to be kept alongSample # Sample Description/Type o f Work ON OFF TIME START STOP Social Security #with sample collection. If the decision is to chip sample, there is the requiredrecord for chain-of-custody, and receipts for laboratorysubmission procedures. Relinquished By: Date: Time: Accepted By: Date: Time:Lab Report Number(s): DeliveryT ype: Drop Off FedEx Mail Other2010-2014 AWDI, LLC - All Rights Reserved. May be Reproduced without changes. TLC Logo used with permission.'