LDST Refresher Course

Attachment 2-A: Sample Visual Inspection Form

SAMPLE VISUAL INSPECTION FORM

Date and Time of Clearance Lead Dust Sampling Technician Client Property Address

Location Identify visible areas of dust, paint chips, painted debris, and deteriorated paint. (Note location: walls, ceiling, floors, doors, windows, trim, cabinets, approximate square footage, etc.)

Chapter 2 Attachment Attachment 2-B: Completed Sample Visual Inspection Form

SAMPLE VISUAL INSPECTION FORM

Date and Time of 8/5/09 11:00AM Clearance Lead Dust Sampling Jane White Technician Client The Smith Family Property Address 78 East Main Street Hammond, IN 89898

Location Identify visible areas of dust, paint chips, painted debris, and deteriorated paint. (Note location: walls, ceiling, floors, doors, windows, trim, cabinets, approximate square footage, etc.) Entry Area

Living Room

Dining Room

Kitchen Window above sink; deteriorated paint on window sash. Client said deteriorated paint was tested and is not lead-based paint. Common Area

Bedroom #1 East window; deteriorated paint on lower sash and dust and paint Small bedroom chips in trough. Client said deteriorated paint was tested and is not (Street Side) lead-based paint.

Bedroom #2 Dust and paint chips on floor. Small bedroom (Back of the house)

Bath #1

Exterior

Chapter 2 Attachment