Free INDIANA STATE DEPARTMENT OF HEALTH - Indiana

REMEDIATION FOLLOW-UP REPORT ON ENVIRONMENTAL INVESTIGATIONS
State Form 53519 (2-08)

INDIANA STATE DEPARTMENT OF HEALTH

INSTRUCTIONS: 1. Fill out the form in its entirety. 2. Mail the completed form to the following address: Indiana State Department of Health Lead and Health Homes Program 2 N. Meridian St., 5J, Indianapolis, IN 46204

I. INVESTIGATOR Investigator Name: Type (check one): Licensed Inspector Local Health Dept.:

Risk assessor

Clearance examiner: __________________

Address (number and street): City: Investigator Signature: State: IN ZIP: Phone: Date (mm/dd/yyyy):

II. UNIT Street Address (number and street): City:

State: IN

ZIP code:

Date of initial inspection: ____/______/_____ (mm/dd/yyyy) Due date for follow ­ up remediation: ____/______/_____ (mm/dd/yyyy) Remediation completed: Yes No

Date remediation completed : ____/______/_____ (mm/dd/yyyy) Clearance samples collected : Clearance passed : Yes Yes No No

Date investigation closed : ____/______/_____ (mm/dd/yyyy)