Free Visual Inspection of Registered Lead-Safe Property, DPH 44005 - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44005 (03/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code

VISUAL INSPECTION OF REGISTERED LEAD-SAFE PROPERTY
The property owner must ensure that a visual inspection is conducted at least once every 13 months for each registered leadsafe property issued a certificate that is effective for 3 years or more. HFS 163, Appendix G, Wis. Adm. Code, provides detailed guidance on conducting a visual inspection.

Registered Lead-Safe Property Address Lead-Safe Property Registration Number Name of Person Conducting Visual Inspection(Print) Date Lead-Safe Certificate Issued (mm/dd/yy) Phone Number of Person Conducting Visual Inspection Date Repaired

Problem(s) Identified (Include a description of the location. For example: flaking paint on kitchen window; chalking paint on garage siding)

Results of Visual Inspection I did not see evidence that the property no longer meets the lead-safe standard. For lead-based painted components, no deteriorated paint is present unless the paint has been proven to be lead-free; all substrate are in good condition and free of visible defect, damage, decay and deterioration; no evidence of water damage is present; and any encapsulation, enclosure, protective covering, or interim control measure remains intact. No visible paint chips are present on the floors, windowsills, window wells, troughs, or soil. I did see evidence that the property may not meet the lead-safe standard at this time, as listed below. Repairs to remove potential lead-based paint hazards will be made as follows: Within 5 working days for interior work in unit(s) _____________________________________________ where a child under the age of 6 occupies the unit. Within 20 working days for interior work in unit(s) _____________________________________________ where the unit is not occupied by a child under the age of 6. Within 20 working days for exterior work, except that repairs identified between October 1 and May 1 will be done by June 1.

SIGNATURE - Person Conducting Visual Inspection

Date of Visual Inspection (mm/dd/yy)