b'REGISTRATIONFORRRP LEAD SAFE WORKPRACTICESand PRE EDUCATION RECEIPTCustomer Name:Address: City - State - Zip:Telephone: FAX:(Home)E-mail:Telephone: (Cell)Type of Home: Frame Masonry OtherAge of Home:Year Built Original Windows:YES NOAge Confirmation: Deed Tax Rolls Owner OtherRenovation Project:Windows Doors Conservatories/Sunrooms Roofing Siding OtherReceipt of Renovation Right Brochure:I have received a copy of the lead hazard information pamphlet Renovate Right informing me of the potential risk of the leadhazard exposure from renovation activity to be performed in my dwelling unit. I received this pamphlet before the work began.Permission Received for Initial Lead Test: I understood that my residence may contain lead coatings on the future renovations I am investigating with the firm noted above.As such, I gave my permission for their representative (signature below) to score a sample component with a razor knife and usean approved EPA Test) to determine if lead is present.I fully understand that this is a preliminary test, and if I decide to proceedwith the renovations, and lead was detected in this preliminary, an official test will need to be done by a Certified Renovator (orother Certified EPA test conductor) to establish official results. The representative will provide me a copy of this form. I understandthere will be slight damage to the component but am aware that the EPA RRP Final Rule require this test for all renovations to beperformed after April 22, 2010 on target homes and child occupied facilities built prior to 1978.The result shown was obtained bya good faith test using EPAaccepted test kits in accordance with EPA instructions for in-home tests.Preliminary Test Result:Lead Detected Lead Not Detected Proof of Previous Abatement Lead AssumedEPA CertifiedCertification #:Renovator: EPA Certified Firm:Certification #:Firm Representative Date:Signature:Homeowner Signature: Date: 2010- 2014 AWDI, LLC All Rights Reserved Do not Reproduce without Permission'