Name
of
Firm:________________________________________________________________
Date
and
Location
of
Renovation:_________________________________________________
Name
of
Assigned
Renovator:____________________________________________________

Copies
of
renovator
qualifications
(
training
certificates,
certifications)
on
file.

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

Copies
of
sampling
personnel
qualifications
(
training
certificates,
certifications)
on
file.

Name(
s)
of
Trained
Workers:____________________________________________________
____________________________________________________________________________

Description
of
Tasks
Performed
by
Trained
Workers:_________________________________
____________________________________________________________________________

Description
of
Training
Provided
to
Workers
by
Renovator:____________________________
____________________________________________________________________________

Warning
signs
posted.

Description
of
work
area
and
containment
practices
used:______________________________
____________________________________________________________________________
____________________________________________________________________________
Description
of
how
waste
was
handled:_____________________________________________
____________________________________________________________________________
Description
of
how
walls,
floors,
and
other
surfaces
and
objects
in
the
work
area
were
cleaned:
____________________________________________________________________________
____________________________________________________________________________
Description
of
post­
renovation
cleaning
verification
process:____________________________
____________________________________________________________________________
____________________________________________________________________________
Description
of
dust
clearance
testing,
if
performed:___________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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

____________________________________________
______________________
name
date
____________________________________________
title
