Instructions: Complete for each testing location beginning with Location 1. Make additional copies of this form as needed. Results Testing Location Number Test Kit Used: Test Kit No.: Description of Tested Location and Component Is Lead Present? Date of Testing (m/d/y) Yes No Presumed unable to determine – Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Date of Testing (m/d/y) Yes No Presumed unable to determine – Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Date of Testing (m/d/y) Yes No Presumed unable to determine – Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Date of Testing (m/d/y) Yes No Presumed unable to determine – Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Date of Testing (m/d/y) Yes No Presumed unable to determine –
Instructions: Complete for each testing location beginning with Location 1. Make additional copies of this form as needed. Results Testing Location Number Test Kit Used: Test Kit No.: Description of Tested Location and Component Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y) Results Test Location Number Test Kit Used: Test Kit No.: Description of Component & Location Is Lead Present? Yes No Presumed – unable to determine Date of Testing (m/d/y)
f01320.docx