Directive #: 08-05 (TED 01)
Revised: June 2008

APPENDIX II: 1-8.

FIGURE II: 1-24. FRONT OF COMPLETED AIR SAMPLING WORKSHEET FORM OSHA-91A

Air Sampling Worksheet U.S. Department of Labor Occupational Safety and Health Administration

1. Reporting ID                    5555555 2. Inspection Number                 123456789 3. Sampling     Number: 497330105 4. Establishment Name                J & N Casting 5. Sampling Date: 06-14-07 6. Shipping Date: 06-15-07 7. Person Performing Sampling (Signature)                Signature 8. Print Last Name       RIMA 9. CSHO ID      Z1234 10. Employee (Name, Address, Telephone Number):         (123) 456-7899   14. Exposure     Information   a. Number: 2   b. Duration: 3.5 Yrs/ ea person      B.J. Albrecht, 850 Lego Road c. Frequency: 6hr./day      Pixar City, CA 99999   15. Weather Conditions: Indoors 16. Photo(s):      Y 11. Job Title: Brass Squeeze Molder Machine Operator - 12 years 12. Occupation Code 17. Pump Checks and Adjustments: 7:30 - ok, 8:30 - ok, 9:30 - ok, 10:30 - ok, 11:30 - ok, 12:30 - ok, 1:30 - ok, 2:30 - ok 13. PPE (Type and effectiveness): Safety glasses and ear plugs, no respirators worn   18. Job Description, Operation, Work Location(s), Ventilation, and Controls Operates glass squeeze molding machine. Fills and compacts sand into mold. Finished molds placed on pouring lines. There are fans but no exhaust ventilation.     Cont'd 19. Pump Number: 10337                          Sampling Data 20. Lab Sample      Number             21. Sample Submission      Number ER300           22. Sample Type P           23. Sample Media MCEF           24. Filter/Tube      Number ER300           25. Time On/Off 6:30am 1:00pm         12:30pm 2:48pm         26. Total Time      (in minutes) 360 108         27. Flow Rate       l/min       cc/min 2.13 2.13         28. Volume      (in liters) 766.8 230 = 996.8 Total volume       29. Net Sample Weight      (in mg)             30. Analyze Samples      for: 31. Indicate Which Samples to Induce in TWA, Ceiling, etc. Calculations Welding Fume T           (Lead & Cadmium)                                         32. Interferences and       IH Comments to Lab 33. Supporting Samples 34. Chain of Custody Initials Date       a. Blanks: ER302 a. Seals Intact? Y     N         b. Rec'd in Lab           b. Bulks c. Rec'd by Anal.       d. Anal. Completed       e. Calc. Checked       f. Supr. OK'd             Case File Page      /                     /                    /  of OSHA-91A (Rev. 1/84)

FIGURE II: 1-25. BACK OF AIR SAMPLING WORKSHEET FORM OSHA-91A

Pre-sampling Calibration Records   P r e   35. Pump Mfg. & SN Gilian 10337 36. Voltage Checked?                      Yes    No 37. Location/T & Alt. I.H. Lab – Area Office   38. Flow Rate Calculations: 2128 2132 2129 39. Flow rate: 2.13 40. Method      Bubble      PR 41. Initials: JR 42. Date/Time: 06/14/07 –5:30am   Post-Sampling Calibration Records   P   o s t 43. Location/T & Alt. I.H. Lab – Area Office   45. Flow Rate: 2.13 44. Flow Rate Calculations: 2129 2131 2133 46. Initials: JR 47. Date/Time: 06/14/07 – 3:35pm   Sample Weight Calculations: 48. Filter No.             49. Final Weight       (mg)             50. Initial Weight       (mg)             51. Weight      Gained (mg)             52. Blank      Adjustment             53. Net Sample      Weight (mg)             54. Calculations and Notes:

APPENDIX II: 1-9.

FIGURE II: 1-26. COMPLETED SOIL SAMPLING WORKSHEET ON A FORM OSHA-91A

Air Sampling Worksheet U.S. Department of Labor Occupational Safety and Health Administration

1. Reporting ID                    0418300 2. Inspection Number                 123456789 3. Sampling     Number: 914687710 4. Establishment Name                Curtis Service, Inc. 5. Sampling Date: 12-05-07 6. Shipping Date: 12-18-07 7. Person Performing Sampling (Signature)                Signature 8. Print Last Name       Cooley 9. CSHO ID      T1234 10. Employee (Name, Address, Telephone Number): It is at the discretion of the CSHO to fill in Sections 10-13, but it is not necessary for the SLTC. 14. Exposure     Information   a. Number: 1   b. Duration: 3 days   c. Frequency: 2-4hr./day   15. Weather Conditions: ˜2" of rain night before (12-04-07) 16. Photo(s):      Y 11. Job Title: Pipe Install Technician/Welder 12. Occupation Code 17. Pump Checks and Adjustments: 13. PPE (Type and effectiveness): Safety glasses and steel toe boots   18. Job Description, Operation, Work Location(s), Ventilation, and Controls In this section, indicate: 1) dimensions of the trench; 2) work being done in the trench; 3) type of protective system or lack of it in the trench; 4) where in the trench or spoil pile was the sample taken; and 5) address or location of the trench.   Cont'd 19. Pump Number:                                Sampling Data 20. Lab Sample      Number             21. Sample Submission      Number 001           22. Sample Type Bulk           23. Sample Media             24. Filter/Tube     Number             25. Time On/Off                         26. Total Time      (in minutes)             27. Flow Rate      l/min       cc/min             28. Volume      (in liters)             29. Net Sample Weight      (in mg)             30. Analyze Samples      for: 31. Indicate Which Samples to Induce in TWA, Ceiling, etc. Calculations S777             Soil Analysis                                         32. Interferences and       IH Comments to Lab 33. Supporting Samples 34. Chain of Custody Initials Date       a. Blanks: a. Seals Intact? Y     N         b. Rec'd in Lab           b. Bulks c. Rec'd by Anal.       d. Anal. Completed       e. Calc. Checked       f. Supr. OK'd             Case File Page      /                     /                    /  of OSHA-91A (Rev. 1/84)