Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Name of Owner/Occupant
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Address:
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City:
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State:
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Zip:
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Contact Number:
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E-mail
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Renovation Information
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Renovation Address
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Unit #:
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City:
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State:
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Zip:
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Certified Firm Name: Pella Windows Address: 9845 S 142nd Street City: Omaha State: Nebraska Zip: 68138 Contact #: 402-861-7913 E-mail: wtrue@pellaomaha.com Certified Renovator Name: Wes True Date Certified: 4/16/2014
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Test Kit Information
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Test Kit 1: Manufacturer: fill in permanent info Manufacturer Date: ? Model: fill in permanent info Serial Number: ? Expiration Date:?
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Test Kit 2: Manufacturer: fill in permanent info Manufacturer Date: ? Model: fill in permanent info Serial Number: ? Expiration Date:?
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Test Kit 3: Manufacturer: fill in permanent info Manufacturer Date: ? Model: fill in permanent info Serial Number: ? Expiration Date:?
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Renovation Address:
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Unit #
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City:
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State:
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Zip:
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Test Location # 1:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 2:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 3:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 4:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 5:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 6:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
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Test Location # 7:
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Test Kit Used:
- Test Kit 1
- Test Kit 2
- Test Kit 3
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Result: Is Lead Present:
- Yes
- No
- Presumed
