DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44012 (Rev. 10/02)
STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code Fax Number (608) 266-9711
NOTIFICATION OF LEAD-BASED PAINT ACTIVITY
Read separate instructions, DPH 44012I, before completing this form. Lead Company Project Number
A. PROPERTY OR RESIDENCE INFORMATION (Check most accurate response)
Type: Commercial Business Day Care/Preschool Government HUD Residential K-12 School Lead-Safe Facility-Certificate Number Lead-Safe Residential-Certificate Number Manufacturing Public Residential (Number of units ) University/College Other Occupancy: Is building occupied or frequented by a child under the age of 6? Yes No If a residence, is the building occupied only by the owner and the owner's immediate family? Property Name, if applicable Street or Fire Code Address City Property Contact Person Name of Property Owner ZIP Code Telephone Number Telephone Number Lead Abatement Temporary Lead Hazard Reduction Renovation/Remodeling
Number of Units
B. PROJECT TYPE
Ordered Lead Abatement Maintenance
C. RESTRICTED PRACTICES
Will any of the following restricted activities be performed? (Check `Yes' if any of the following apply) Abrasive Blasting/Sandblasting Power Washing Machine Chipping/Grinding/Planing/Sanding Removing Components New Start Date New End Date End Date No Yes No Chemical Paint Stripping Use of Heat Gun Cancellation Emergency
D. TYPE OF NOTIFICATION
Original Notice Start Date Shift(s): Revision Number
E. PROJECT DATES / HOURS
1st 2nd 3rd Weekend Yes
F. CERTIFIED LEAD ABATEMENT COMPANY INFORMATION (Company performing lead-based paint activities)
Company Name Street Address City Company Contact Person State ZIP Code Telephone Number WI Lead Certification No.
G. LEAD IDENTIFICATION
Lead Assumed Present Lead Investigator Name Site Tested Unknown WI Lead Certification No . Interior work Exterior work Estimated exterior square footage Estimated Project Cost $ Date Lead Identified
H. PROJECT INFORMATION
Number of rooms
Number of windows
I am a certified lead supervisor and authorized representative for the certified lead company above. I certify that to the best of my knowledge this project complies with HFS 163, Wisconsin Administrative Code, and all applicable state, federal, and local regulations.
SIGNATURE Lead Supervisor/Authorized Representative
Signee's WI Lead Certification ID No.
DPH 44012 (Rev. 10/02) Page 2 Note: Local ordinances may apply to this lead project. For information about a local ordinance, contact the local health department. When a lead permit is required by a City of Milwaukee ordinance, submit this form (and fee when required) to the City of Milwaukee Health Department (MHD) and show, a valid Wisconsin lead supervisor certification card. MHD may suspend or deny a permit for failure to comply with any municipal requirement relating to lead hazard reduction. Call MHD at 414-286-0387 for detailed information. Local Lead Permit Number The following format is being provided as an example of information that must be included in a Mandatory Written Abatement Report. The use of this format is optional and a company may choose to use a different format, but a written report must be completed. Mandatory Written Abatement Report Complete number 1 prior to commencing abatement activity. Complete numbers 2 and 3 after abatement project is completed. 1. List name(s) and WI Lead Certification number of each supervisor assigned to project:
Abatement dates if different from dates on the front of side of the form.
Start Date: 3.
Attach or provide here a detailed description of the abatement, including locations of rooms and components where abatement occurred, abatement methods used for each component and reasons for selecting them, and any suggested monitoring of encapsulants or enclosures. If a copy of the abatement contract or orders is attached, describe any changes from the contract or order and give any additional details needed to provide a clear picture of the actual abatement.
Attach a copy of the Clearance Report from the lead company that conducted the clearance for this project and Division of Public Health Occupant Protection Plan that was prepared before the project started. Give a copy of the full abatement report, including the Notification of Lead-Based Paint Activity (this form page 1), Occupant Protection Plan, and Clearance Report, to the person who contracted for the abatement services. Retain a copy for the company records.
DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44012I (10/02)
STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code
Instructions for Completing the Notification of Lead-Based Paint Activity The lead abatement supervisor must submit the Notification of Lead-Based Paint Activity (DPH 44012) for receipt by the Department of Health and Family Service a minimum of two working days before the project starts. Mail the completed form to the Department of Health and Family Services, Asbestos and Lead Section, Room 137, P.O. Box 2659, Madison, WI 53701-2659, or fax to (608) 266-9711. Working days are counted by including the day the notice is received and excluding the day the project starts. For example, a project for a notice received on Friday, may start on Tuesday, and a project for a notice received on Monday, may start on Wednesday. Provide the Lead Company's Project Number. The project number and WI Certification Number for the lead abatement company must be included on any revisions to the notice. Every item in sections A through H must be completed. (Refer to Chapter HFS 163.14(2), Wisconsin Administrative Code for the regulations concerning notification of lead-based paint activity.) A. PROPERTY OR RESIDENCE INFORMATION. Type. Check one box that most accurately describes the use of the portion of the building where this lead-based paint activity will be conducted. Commercial Business. Commercial business, such as a restaurant, store, shopping mall, health club, or private business not involved in manufacturing. Day Care / Preschool. Premises used for the supervision of children of preschool age. Government. Building owned, managed or used by a local, state or federal governing body or organization. HUD Residential. Pre-1978 housing that is federally owned or receives federal assistance. K-12 School. Public or private academic school for children in any grade: kindergarten through 12. Lead-Safe Facility. Premises with a valid certificate of lead-safe status in effect, that is not a dwelling or dwelling unit. Lead-Safe Residential. Dwelling or dwelling unit with a valid certificate of lead-safe status in effect. Manufacturing. Building involved in manufacturing. Public. Building not otherwise described that is routinely used by the public, such as a church, library, YMCA, or other club. Residential. Dwelling, apartment, or other area where any person resides, that does not have a valid certificate of lead-safe status in effect. University / College. University or college. (Check "Commercial business" box for any university-owned commercial business that is not directly related to the education of university students.) Other. Any other building. Explain how the building is used. Occupancy. Check the correct response to both questions. Always answer "yes" to question number 1 if the building or any portion of the building is used as a day care, pre-school and or provides services to children on-site. Complete all information requested about the property where the project will be conducted. For "Property Contact Person," enter the name and telephone number of the person to be contacted about the project. B. PROJECT TYPE. Check one box as follows: Ordered Lead Abatement. A local, state, or federal health agency has ordered the lead abatement to be done. Abatement includes any measure intended to permanently reduce a lead hazard under normal conditions, such as removal, enclosure, or encapsulation of a leadbased paint component. Attach orders that describe what work is to be done or have orders at the work site for review by state or local government staff. Lead Abatement. Lead abatement project other than ordered lead abatement work. Abatement includes any measure intended to permanently reduce a lead hazard under normal conditions, such as removal, enclosure, or encapsulation of a lead-based paint component. Temporary Lead Hazard Reduction. A non-abatement lead-based paint hazard reduction activity, such as cleaning or paint stabilization. Renovation/Remodeling. Activity that disturbs or removes lead-based paint, where the intent is not to reduce or eliminate a lead-based paint hazard. Maintenance. Activity that disturbs lead-based paint in the process of keeping buildings in good repair, and is not intended or designed to reduce lead-based paint hazards. C. RESTRICTED PRACTICES. Check the "Yes" box if any of the restricted practices listed will be performed during the lead-based paint activities. D. TYPE OF NOTIFICATION. Check one box as follows : Original notice. First written notice for a project that is not an emergency.
DPH 44012I (10/02) Page 2 Revised notice. Changes to a previously written notice. Enter the total number of revised written notices for this project, not counting the original written notice. A new notice, not a revision, must be submitted when a project change is submitted after the project end date on the previous notice. Note: A revised notice is required when the project start or end date changes. To make changes and tracking easier, keep a copy of any notice you submit. Then, to revise a notice, make a photocopy of the last notice you submitted, put a line through the information being changed, enter the new information, keep a photocopy and send the revised notice to the Asbestos & Lead Section. The Asbestos & Lead Section must receive your revised notice: · a minimum of 2 working days before the project begins when the start changes to an earlier date. · a minimum of 1 working day before the original start date when the start date changes to a later date. · no later than the original end, date when the project will not end on the date in the notice. Cancellation. The project has been canceled. Note: Once canceled, a notice cannot be reactivated. If the project continues or restarts after a notice is canceled, submit a new notice. Emergency notice. Project is being started on an emergency basis with less than 2 working days notice. Keep records that verify an emergency existed. Note: Notice is required before the project starts. If emergency notice is not sent by fax, emergency notification may be made by telephone followed by written notice to the Asbestos & Lead Section within 48 hours. E. PROJECT DATES/HOURS. Dates - Enter the dates you expect to start and end the actual lead-based paint project. Note: A revised notice must be submitted whenever a start or end date changes. Accurate information is necessary to allow an onsite review of the project to be conducted. If no one is present at the facility when an on-site review is conducted, the contractor may be found out of compliance with Chapter HFS 163, Wis. Administrative Code. Shift(s) - check all work shifts that apply for this lead abatement/hazard reduction project. First shift, approximately 7 a.m. 3 p.m. Second shift, approximately 3 p.m. 11 p.m. Third shift, approximately 11 p. m. 7 a.m. Check the appropriate box regarding weekend work on the lead abatement/hazard reduction project. F. CERTIFIED LEAD ABATEMENT COMPANY. Enter the certification number, name, and address of the certified lead abatement company. Any company, partnership, corporation, sole proprietorship, association, governmental agency or other entity that offers, supervises, or performs lead-based paint activities, including abatement, is required to be certified as a lead company. An individual may not conduct abatement except under a certified lead company. Enter the name and telephone number of the person to be called with questions about the project. Note: The lead company certification number is located on the certificate mailed to the lead company after certification approval was granted. If you cannot locate your certification number, please contact the Asbestos & Lead Section at (608) 261-6876. G. LEAD IDENTIFICATION. Check one box as follows. Lead Assumed Present. You assume lead is present, but testing or sampling was not done. Site Tested. A lead inspection or risk assessment was conducted and results indicate the presence of lead-based paint. Unknown. It is not known if testing or sampling was conducted. If Site Tested box is checked, enter the consultant's name, the consultant's WI lead certification identification number, which will start with either "LII", "LHI" or "LRA". Also, provide the date the inspection or risk assessment report was completed in the space for "date lead identified". Note: The lead inspector or risk assessor must give a written report to the person paying for the lead investigation after the investigation is completed. In addition to the results of the lead inspection or risk assessment, this report must include the consultant's name, WI lead certification identification number, and the date the inspection or risk assessment was completed. A copy of this report should be provided to the contractor to ensure abatement or interim controls are conducted with accurate information. H. PROJECT INFORMATION. Check the interior and/or exterior box as appropriate. If appropriate, enter the number of rooms that will be undergoing lead-based paint activities. If appropriate, enter the number of windows that will be undergoing lead-based paint activities. For exterior projects, the estimated square feet of the lead-based paint activity. The estimated cost of the lead-based paint activity. The notification must be reviewed for accuracy and signed by the certified lead supervisor who is authorized to represent the lead company. Enter the certified supervisor's WI lead certification identification number and the date the notice is actually signed. Do not enter a date different from the actual date of signature. Side 2 of the notification form is optional. It may be used to record information which is required as part of the abatement report.