Free INDIANA STATE DEPARTMENT OF HEALTH - Indiana

NOTIFICATION OF LEAD ABATEMENT ACTIVITIES
State Form 49150 (R3 / 2-08) Approved by State Board of Accounts, 2008

INDIANA STATE DEPARTMENT OF HEALTH

INDIANA STATE DEPT. OF HEALTH Lead and Healthy Homes Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250

http://www.in.gov/isdh/programs/lead/

INSTRUCTIONS:

1.

This form must be used to notify of lead abatement activities pursuant to 326 IAC 23. If accessing this form on-line, you may print the blank form and fill it out by hand for submission with original signatures.

2. Submit one notification form for each address for which you are seeking approval. 3. Please type or print in ink. 4. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier's Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207 5. Notification is only required when a project is designed to permanently eliminate Lead based paint hazards. * Per Indiana Rule 326 IAC 23-3-7, all notifications to the ISDH must be submitted on the State Form 49150. * Per 326 IAC 23-3-16, lead abatement fees will be assessed quarterly to owners/operators submitting notifications during the previous quarter. 6. Type of Notification-326 23-4-6 A. If this is the original notice, please check the appropriate space on the notification form. B. If this is a revised notice, please check the appropriate space on the notification form. The revised notice must be postmarked and sent by certified mail, return receipt requested, at least 5 working days or delivered at least 2 working days before the start date of lead abatement activity specified in: (1) the notice being revised and (2) the new revised notice. Facsimiles will be accepted by the ISDH. C. All revisions must include a copy of the notice being revised. D. If this is a cancelled notice, please check the appropriate space on the notification form. E. Courtesy Notification. 7. Facility Information-326 IAC 23-4-6(1)(D) A. Either the owner or operator must submit the notice. B. The owner means the individuals(s) who own the property or lease the property. C. The operator means the lead abatement contractor. D. Specify the name, address, telephone number, Indiana license number and license expiration date, of the: 1. lead abatement contractor(include the hours and days of operation) 2. inspector who conducted the inspection prior to abatement 3. risk assessor who made a Lead hazard assessment 8. Type of Operation-326 IAC 23-4-6(2)(D) A. Refer to the definitions of encapsulation, enclosure and emergency abatement in 326 IAC 23-1. B. Emergency abatement operations have additional notification requirements. Owner/Operator must also complete Section XIII of notification form. 9. Procedures, Including Analytical Methods, If Appropriate, Used To Detect the Presence and Amounts of Lead Based Paint.326 IAC 23-4-6(2)(F) 10. Approx. Amounts of Lead To Be Removed - 326 IAC 23-4-6(2)(G) Specify the amount of Lead Based paint to be removed in terms of linear feet or square feet on facility components. 11. Scheduled Dates of Lead Based Paint Removal - 326 IAC 23-4-6(2)(I) This means the actual start and end date as indicated by the posting and removal of lead-based paint hazard demarcations in the work area. 12. Facility Description - 326 IAC 23-4-6(2)(E) and (H) Include the building name, floor and room number(s) if available where the lead abatement activity will take place. Provide enough detail that an unfamiliar inspector can find the abatement without asking anyone. 13. Description of planned activity work to be performed and methods to be employed, including techniques to be used and a description of the affected facility components 326 IAC 23-4-6(2)(J) Briefly describe the methods to be used such as encapsulation, enclosure, heat scrapping, etc..., list the affected facility components such as doors, windows, and floors.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49150 (R3 / 2-08)

Notification of Lead Abatement Activities 2/08

14. Description of work practice and engineering controls to be used to comply with this rule, including lead removal and waste handling emission control procedures. 326 IAC 23-4-6(2)(K) Examples of work practices and engineering controls to prevent lead emissions at the site would include: the use of water or wetting agents, containments, and negative air units during removal; daily clean up, placing waste into leak tight containers and secure storage. 15. Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead based hazard and warrants immediate action. 326 IAC 23-4-6(2)(P) Procedures could include any steps taken to immediately minimize exposure potential. A notification would need to be given as early as possible, but not later than the following work day. 16. Waste Transporter- 326 IAC 23-4-6(2)(Q) Provide the name, address, and telephone number of only the lead waste transporter. This should include the waste transporter name, street address, city, state, zip code, contact person, and telephone number. 17. Lead Disposal Site- 326 IAC 23-4-6(2)(M) Provide the name and location of the landfill where the lead waste material will be deposited. This should include the name, street address, city, state, zip code, waste disposal site contact person, and telephone number. 18. Emergency lead abatement- 326 IAC 23-4-6(2)(P) A. Specify: 1. The date and hour that the emergency occurred, 2. a description of the sudden unexpected event, and 3. an explanation of how the event causes a lead-based paint hazard and warrants immediate action. B. An "Emergency abatement operation" is an unplanned operation that results from a sudden unexpected event that if not immediately attended to presents a safety or public health hazard. 19. Certification Statement and Signature by Owner/Operator-326 IAC 23-4-6(2)(N) Self-explanatory.

Reset Form

NOTIFICATION OF LEAD ABATEMENT ACTIVITIES
I. Type of Notification (check one): Original Revised* Cancelled Courtesy *Must include copy of notification which is being revised. II. Faclity Information (Identify owner, lead abatement contractor, inspector, risk assessor)

Facility Owner: __________________________________________________________________________________ Address: ______________________________________________________ City: ___________________________ State: _____ ZIP: __________ Contact Name: ________________________ Telephone: ________________________

Lead Abatement Contractor: ________________________________________________________________________ Address: ________________________________________________ City: __________________________________ State: __________ ZIP: _______________ Contact: ___________________________ Telephone: _________________ IN License Number: ___________________ Expiration Date: _______________

Hours of Operation Days of Operation

_____ A.M. to _____ P.M. Monday Tuesday

_____ A.M. to _____ P.M. Wednesday Thursday Friday

All Shifts _____ Saturday Sunday

Inspector: ______________________________________ Address: _______________________________________ City: ________________________ State: ____________ IN License Number: ______________________________ Expiration Date: __________ Telephone: ____________

Risk Assessor: _________________________________ Address: ______________________________________ City: ________________________ State: ___________ IN License Number: _____________________________ Expiration Date: __________ Telephone: ___________

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49150 (R3 / 2-08) III. Type of Operation (check all that apply): Interior Wet Stripping Encapsulation Exterior

Notification of Lead Abatement Activities 2/08

Dry Stripping

Enclosure

Emergency

IV. Procedures including Analytical Methods, if appropriate, used to detect the Presence and Amount of Lead: _________________________________________________________________________________________________ V. Approximate amount of lead-based paint Linear Feet Surface Area (sq.ft.) VI. Scheduled dates of lead-based paint removal Start Date Completion Date

VII. Child Occupied Facility Description: ____________________________________________________________ ________________________________________________________________________________________________ Building Name: __________________________________________________________________________________ Street Address: ________________________________ City: _______________ , IN County: _________________ Affected component or portion of facility: ___________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Exact activity location: ___________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Building size (sq.ft.): _______________________ Number of floors: ________ Age of structure: ______________ Present use: ________________________________ Prior use: __________________________________________ VIII. Description of planned activity work to be performed and methods to be employed, including techniques to be used and a description of the affected facility components: __________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

IX. Description of work practices and engineering controls to be used to comply with this rule, including lead removal and waste handling emission control procedures: ____________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________

X. Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead hazard and warrants immediate action: ____________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

XI. Waste Transporter Name: _________________________________________ Address: _______________________________________ City: ___________________ State: _____ ZIP: _______ Contact: _____________ Telephone: _______________

XII. Lead Disposal Site Name: _________________________________________ Address: _______________________________________ City: ___________________ State: _____ ZIP: _______ Contact: _____________ Telephone: _______________

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49150 (R3 / 2-08)

Notification of Lead Abatement Activities 2/08

XIII.

For Emergencies Only: Date and hour of emergency: ______________________________________________________________ Explanation of how the event caused a lead hazard and warranted immediate action: _______________

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

XIV.

I hereby certify that the information in this notification is correct and that I will only use Indiana-licensed workers and project supervisors, to implement this lead abatement activity, which have been trained under 326 IAC 13-17-14-5; 40 CFR 745. The trained individual(s) along with evidence that the required training was accomplished shall be available at the job site during actual work hours.

_______________________________________________ Owner/operator (signature)

______________________________________________ Date (month, day, year)

_______________________________________________ Owner/operator (printed)

_______________________________________________ Affiliation

FOR OFFICE USE ONLY
Postmark: Date Reviewed: Reviewed by: Deficiencies:

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