DU204SA-15-R-0002_Attachment_3.pdf

Attachment 3 to Section J

PAINT / DUST / DEBRIS DATA FORM (Use additional sheets as necessary PRINT all entries) Page of

Sampling Site Address: Clearance Examiner Name:

Certification

Title/No:______________________________

Clearance Examiner Firm:

Date:

Location Description (Location where dust, painted debris, or paint chips were seen; or where sample of settled dust was collected)

Comments (For example: dust.

deteriorated paint, painted debris, paint chips, floor sample, interior window sill sample, window trough sample)

Sample ID Number

Dust Sampling Dimensions

(if applicable) [in] x [in] to +/- 1/8 in

Check here if NO deteriorated paint, visible dust, painted debris, or paint chips were observed in the clearance area. Note: Dust samples must be taken even if no deteriorated paint, visible dust, painted debris, or paint chips were observed.