*Sample Location: Samples may consist of either single or composite samples. To adequately assess contamination levels, a minimum of one composite sample per room is recommended. A composite sample consists of no more than four 100 cm2 sampling locations taken from the same room. Local Health Approved: Yes No SIGNATURE: DATE: Sample ID Sample Analyte Area Pre Decon Post Decon Number Location Sampled Results Results Sample ID Sample Location* Analyte Area Pre Decon Post Decon Number Sampled Results Results SM1 Living room Meth 400 cm² SM2 Bathroom ceiling Meth 100 cm² fan SM3 Septic (strong VOC (to be 1 quart solvent odor reported in detected) ppm) SM4 Kitchen Meth 400 cm² SM5 Sample Blank (for Meth QA/QC) DECONTAMINATION PROCEDURES Pre Decontamination Sampling Photos Includes high quality, dated photos, showing template over sampled area with sample ID number and a point of reference. Analytical Request Form/Chain-of-Custody Record Includes chain of custody verification, information necessary for laboratory analysis and LHO interpretation: sample number, sample location, area sampled, analyte sampling for, detected odors at VOC sampling locations. See sample form at the end of this template. Pre-Decontamination Sampling Results Table: (With copy of report from analytical lab.)
Sample ID Number Sample Location* Analyte Area Sampled Pre Decon Results Post Decon Results SM1 Living room Meth 400 cm² SM2 Bathroom ceiling fan Meth 100 cm² SM3 Septic (strong solvent odor detected) VOC (to be reported in ppm) 1 quart SM4 Kitchen Meth 400 cm² SM5 Sample Blank (for QA/QC) Meth *Sample Location: Samples may consist of either single or composite samples. To adequately assess contamination levels, a minimum of one composite sample per room is recommended. A composite sample consists of no more than four 100 cm2 sampling locations taken from the same room. Local Health Approved: Yes No SIGNATURE: DATE: DECONTAMINATION PROCEDURES Pre Decontamination Sampling Photos Includes high quality, dated photos, showing template over sampled area with sample ID number and a point of reference. Analytical Request Form/Chain-of-Custody Record Includes chain of custody verification, information necessary for laboratory analysis and LHO interpretation: sample number, sample location, area sampled, analyte sampling for, detected odors at VOC sampling locations. See sample form at the end of this template. Pre-Decontamination Sampling Results Table: (With copy of report from analytical lab.) Sample ID Number Sample Location Analyte Area Sampled Pre Decon Results Post Decon Results
333-191.docx