Name of Firm:________________________________________________________________

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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