Lead Hazard Control Clearance Sampling Certification Form
Date_____
Name of Certified Risk
Assessor_________________________________________________
License No.________________________________________________
Work Task Data Element ________
Sample quantity and location:
Windows _____________
Floors ______________
Exterior Soils ______
Date of sample collection_______________Date Shipped to lab________________
Shipped by_________________________________________________________________
Signature
I certify that the clearance samples taken meet the clearance sampling
requirements of this contract.
By:____________________
Date:___________________
Certified Risk Assessor
Print name and Title:__________________________________________
CONTRACTING OFFICER ACCEPTANCE OR REJECTION
I have inspected sampling locations and procedures and have found them to be
_______Acceptable, meet contract requirements.
_______Unacceptable, do not meet contract requirements, Contractor is
directed to resample.
By: Contracting Officer's Representative
Signature
Date
Print Name and Title____________________________________________________
SECTION 13281A
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