<< Back to Section II: Chapter 1:  Personal Sampling For Air Contaminants



Directive Number: 08-05 (TED 01)
Revised: 6/24/2008
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
DOL Logo 
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 Checkbox l/min
     cc/min Checkbox 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 Checkbox Yes   No Checkbox 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 Checkbox  Bubble
   PR Checkbox  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 
DOL Logo 
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 Checkbox l/min
     cc/min Checkbox 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)