2507.05 Sample Renovation Recordkeeping

Sample Renovation Recordkeeping Checklist

Form Approved OMB No. 2070-0195 Expires 2/29/24

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 kit or test results from an EPA-recognized laboratory on collected paint chip sample, used by certified
renovator to determine whether lead was present on components affected by renovation (identify method
used, type of test kit used (if applicable), laboratory used to conduct paint chip analysis, 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)
___
Vertical containment installed if property line prevents 10 feet of ground covering, or if necessary 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

This collection of information is approved by OMB under the Paperwork
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