b'SAMPLE PAINT CHIPCOLLECTION FORMCustomer Name:Address: Telephone: E-mail: (Home)Renovation InformationFill out all of the following information that is available about the Renovation Site, Firm and Certified Renovator. Renovation Address: _____________________________________________________ Unit #: ___________ City: _______________________State: _________ Zip code: ____________ Certified Firm Name: ______________________________________________________________________ Address: ________________________________________________________________________________ City: _______________ State: _____________Zip code: ____________ Contact #: (____) ____- ______ Email: ____________________________________________________________ Certified Renovator Name: ________________________________________________________________ Date Certified ________/ __________/____________ Paint Chip Sample InformationFor each sample collected, fill out all of the following information Sample Identifier: ___________________________Sample Collector Name: ___________________________________________________________________ Sampling Location: ________________________________________________________________________ Sampling site description: ___________________________________ Date of Collection: ____/_____/_____2Sample Dimensions (cm): _______________________Calculate Sample Areacm_______________________ NLLAP-recognized entity and location: _______________________________________________________ Paint Chip Sample Collection Form Page __ of __Submission date: ____/_____/_____ Results: _______________________ Result Date: ____/_____/_____ EPA Certified Renovator:Certification No. 2010-2014 AWDI, LLC.- All Rights Reserved. May be copied without changes for personal use but not resold in any form.'