Form Sample renovation Sample renovation Sample renovation recordkeeping checklist

Sample Renovation Recordkeeping Checklist

Name of Firm:________________________________________________________________

Date and Location of Renovation:_________________________________________________

Brief Description of Renovation: _________________________________________________

____________________________________________________________________________

Name of Assigned Renovator:____________________________________________________

Name(s) of Trained Workers, if used:______________________________________________

____________________________________________________________________________

Name of Dust Sampling Technician, Inspector, or Risk Assessor, if used:__________________

_____________________________________________________________________________

 Copies of renovator and dust sampling technician qualifications (training certificates, certifications) on file.

 Certified renovator provided training to workers on (check all that apply):

 Posting warning signs  Setting up plastic containment barriers

 Maintaining containment  Avoiding spread of dust to adjacent areas

 Waste handling  Post-renovation cleaning

 Test kits used by certified renovator to determine whether lead was present on components affected by renovation (identify kits used and describe sampling locations and results):_____________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 Warning signs posted at entrance to work area.

 Work area contained to prevent spread of dust and debris

 All objects in the work area removed or covered (interiors)

 HVAC ducts in the work area closed and covered (interiors)

 Windows in the work area closed (interiors)

 Windows in and within 20 feet of the work area closed (exteriors)

 Doors in the work area closed and sealed (interiors)

 Doors in and within 20 feet of the work area closed and sealed (exteriors)

 Doors that must be used in the work area covered to allow passage but prevent spread of dust

 Floors in the work area covered with taped-down plastic (interiors)

 Ground covered by plastic extending 10 feet from work area—plastic anchored to building and weighted down by heavy objects (exteriors)

 If necessary, vertical containment installed to prevent migration of dust and debris to adjacent property (exteriors)

 Waste contained on-site and while being transported off-site

 Work site properly cleaned after renovation

 All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for removal

 Work area surfaces and objects cleaned using HEPA vacuum and/or wet cloths or mops (interiors)

 Certified renovator performed post-renovation cleaning verification (describe results, including the number of wet and dry cloths used):________________________________

_______________________________________________________________________________________________________________________________________________

 If dust clearance testing was performed instead, attach a copy of report.

 I certify under penalty of law that the above information is true and complete.

_________________________________________________ ________________________

name and title date