ICR Attachment 9: Sample Form - 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 Worker(s), 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
weighed 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
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