Appendix I2.
Form Approved
OMB No. 0923-0048 Exp. Date 06/30/2022
FORM 110
ATSDR
estimates the average public reporting burden for this collection of
information as 10 minutes per response, including the time for
reviewing instructions, searching existing data/information sources,
gathering, and maintaining the data/information needed, and
completing and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond
to a collection of information unless it displays a currently valid
OMB Control Number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0923-0048).
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Place ID Sticker Here |
Inspector and Date |
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New Form for Each Room Draw Diagram on Reverse Side of Sheet (Indicate North) |
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INTERIOR XRF Instrument No: ________________________ |
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Room No. __________ Total No. Doors __________ Total No. Windows __________ |
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Test Component |
Condition (I or D) |
Deterioration (Percent) |
XRF Result (mg/cm2) |
Comments |
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Window Sash |
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Windowsill |
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Door |
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Door Jamb |
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Floor |
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Wall |
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Baseboard |
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Radiator |
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Cabinets/Shelves |
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Other |
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Condition
Intact (I): no obvious visible deterioration
Fair (D): peeling, chipping, blistering, flaking, worn, chalking, alligatoring, cracking, or otherwise becoming separated from the substrate.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Young, Aaron (ATSDR/OAD/OCHHA) |
File Modified | 0000-00-00 |
File Created | 2023-08-27 |