DU204SA-15-R-0002_Attachment_5.pdf

Contact Name:

Attachment 5 to Section J

CLEARANCE SUMMARY REPORT Page ___ of ___ (Use additional sheets as necessary; PRINT all entries) Date:____________ Sampling Site Description: __________________________________ Sampling Site Address: ________________________________________________________ Client Telephone Number:

Client Organization: ___ Client Address:

Visual Inspection (circle one): Pass Fail

Sampling Location Description Wipe Sample ID Number

Surface Sampled¹

(circle one)

Laboratory

Results ²

[pg/ft

Pass/Fail

(circle one)

F S T

Pass Fail

F S T Pass Fail

F S I

F S T Pass Fail

F S I

¹ Surface Sampled: F = Floor Wipe; S = Window Sill; and, T = Window Trough

Laboratory Results reported to two (2) significant figures

US EPA Lead Clearance Standards: floor, 40 µġ/ft

; interior window sill, 250 µġ/ft window trough 400 µġ/ft

Overall Clearance Result (circle one): Pass Fail Trained (non-certified) Sampling Technician (if applicable):

Printed Name: _________________________________________ Signature: ________________________________________________ Date: ___________________ Certified Inspector, Certified Risk Assessor, or Certified Sampling Technician (circle one) Printed Name: _________________________________________________________________ Signature: _______________________________________________ Date: ___________________ Certificate Number: __________________________ State for which Certification is held: _________ Name of Certified Inspection or Risk Assessment Firm: ___