b'Test Kit Documentation - TEST KIT 2A Custom : DOCUMENTATION FORM Page 1 of__ www.certifiedrenovator.comer NameOAddress: The Certified Firm is responsible to submit a report Co Telephone: E-mail: to the person contracting for the work (Certified (Home) ERenovation Information:Renovator) containing the manufacturer, modelnumber of kit, description of components tested, Fill out all of the following information that isavailable about the Renovation Site, Firm, and Certified Renovator. location of these components and the results of thetesting. Renovation Address: ____________________________________________________Unit# ______ City: ________________State: ______Zip code: ____________Certified Firm Name: __________________________________________________________________ A copy is to be retained along with all the otherAddress: ___________________________________________________________________________ documentation for a minimum of 3 years like the City: ________________State: ______Zip code: ____________ Contact #: (____)____- _____ Email: ______________________________________ rest of the records. Certified Renovator Name: Date Certified:/ /Test Kit Information:Test Kit InformationUse the following blanks to identify the test kit or test kits used in testing components. Test Kit #1Manufacturer: _______________________________________Manufacture Date: _____/_____/_____ Model: _____________________________________Serial #: _______________________________ Expiration Date: _______________________________ Test Kit #2Manufacturer: _______________________________________Manufacture Date: _____/_____/_____ Model: _____________________________________Serial #: _______________________________ Expiration Date: _______________________________ Test Kit #3Manufacturer: _______________________________________Manufacture Date: _____/_____/_____ Model: _____________________________________Serial #: _______________________________ Expiration Date: _______________________________ EPACertified Renovator:Certification No.2010 AWDI, LLC.- All Rights Reserved. May be copied without changes for personal use but not resold in any form.Lead Test Record - 2B OFFICIAL LEAD TEST RECORDWhen lead is suspected for a job, each component Customer Name:source needs to be tested with the Lead Check swab Address: test kit (or other EPA Recognized lead testing City, State, Zipmethod) and the results documented. Certified Test Provider Renovator Inspector Dust Sampling Technician Risk Assessor OtherThe results shown were obtained by a good faith test using EPAaccepted methods in accordance with EPA approved tests.EPA Certified Firm:Certification No.If a professional tester or risk assessor is needed, Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3they too must record the results on each locationDescription of Component tested including location:of components that will be disturbed during theResult: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________renovation.Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Description of Component tested including location:The Lead Test Record Form can be filled out at theResult: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________time of testing. Later, the results can be transferredTest Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3to the RRP Completion Form to consolidate the Description of Component tested including location:records. The back of this form contains a grid onwhich you can locate the test Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________areas in a simple house floor Page __________ of ___________ Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3 Description of Component tested including location:Description of Component tested including location:plan. Save this form with your Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _____ / _____ / _____Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Description of Component tested including location: Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________records. Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _____ / _____ / _____Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Description of Component tested including location: Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _____ / _____ / _____Test Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3 Description of Component tested including location:Description of Component tested including location:Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _____ / _____ / _____Location Grid of NTuemstebde r - Components ByResult: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________GriPdasnhdo Cows Rmpooomn(esn)t s luobcjaetcito nto(s). RRTest Location #________ Test Kit Used (Circle only one)Test Kit #1 Test Kit #2 Test Kit #3Description of Component tested including location:Result: Is Lead Present?(Circle only one)YES NO Presumed Date of Test: _________ / _________ / __________2010-2014 AWDI, LC - Al Rights Reserved. May be Reproduced without changes. TLC Logo used with permision. 2010-2014 AWDI, LLC - Al Rights Reserved. May be Reproduced without changes. TLC Logo used with permission.'