Free Application for Registration of Lead-Free or Lead Safe Property, DPH 44011 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 44011 (03/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code (608) 261-6876

APPLICATION FOR REGISTRATION OF LEAD-FREE OR LEAD-SAFE PROPERTY
Read instructions before completing. This form must be completed to register a Certificate Of Lead-Free or Lead-Safe status for a property with the Department of Health and Family Services. Return the completed form to the address listed on page 2 of this form.

COMPANY INFORMATION
Company Name Mailing Address City Records Address City Telephone Number ( ) Cellular Telephone Number ( ) Email Address State Zip+4 State Zip+4

Fax Telephone Number ( ) Pager Telephone Number ( )

FACILITY INFORMATION (Only one facility per application)
Facility Type (Check one of the following) Commercial Business Day Care / Preschool Lead-Safe Facility University Lead-Safe Residential Unknown K-12 School Manufacturing Government Public HUD Residential Residential

Occupancy Type (Check one of the following) Owner Occupied Facility Name, if applicable Street Address City Property to be Registered Entire building Single dwelling unit Common Area Description Total No. of Units__________ Property Owner/Authorized Representative Contact Person Telephone Number or other contact info e.g. email address ( ) Unit Description State Zip Tenant / Rental Unknown

CERTIFICATE FEE
Enclose a check or money order payable to Department of Health and Family Services (DHFS). Check one of the following. Lead-Free certificate fee enclosed - $75.00 ($50 certificate fee plus $25 additional processing fee) Lead-Safe certificate fee enclosed - $50.00 ($25 certificate fee plus $25 additional processing fee)

AFFIDAVIT OF APPLICANT
I affirm that, to my knowledge, the information on this form completely and accurately reflects the investigation conducted by myself or other staff under my control. I understand that false or forged statements made in connection with this application may be grounds for revoking the lead-safe / lead-free property certification.

SIGNATURE ­ Certified Lead Hazard Investigator, Inspector, or Risk Assessor

Date Signed (mm/dd/yy)

DPH 44011 (03/02) Page 2

ATTACHMENTS
For all applications, certified lead hazard investigator, inspector, or risk assessor must check the following materials are attached and submitted. APPLICATION FOR REGISTRATION OF LEAD-FREE OR LEAD-SAFE PROPERTY (DPH 44011) INVESTIGATION PROTOCOL (DPH 44011, Pages 3 and 4) APPLICABLE INVESTIGATION INFORMATION. Enclose investigation information sheets for the types of investigations conducted. LEAD-FREE INSPECTION INFORMATION (DPH 44011, Pages 5 and 6) LEAD-SAFE INVESTIGATION INFORMATION (DPH 44011, Pages 7 thru 11) Certificate Fee. If applying for a Lead-Free Certificate, enclose $50.00. If applying for a Lead-Safe Certificate, enclose $25.00. Payment must be in the form of a check or money order payable to DHFS (Department of Health and Family Services). If you have questions regarding the information on this form please call (608) 261-6876. If mailing, use the Mailing Address listed below. Applications may be hand delivered to the Street Address. Return completed application to: Mailing Address Department of Health and Family Services Asbestos and Lead Section, Room 137 P.O. Box 2659 Madison WI 53701-2659 Street Address Department of Health and Family Services Asbestos and Lead Section One West Wilson Street, Room 137 Madison WI 53703

DPH 44011 (03/02) Page 3

INVESTIGATION PROTOCOL
General Information Report status at time of investigation. The term "investigation" is used when the activity may be part of either a lead-free inspection or a lead-safe investigation. Unless proven to be lead-free by a qualified individual, all paint is considered to be lead-based paint. Check boxes that apply and fill in appropriate information.

A 101 102 103 104 105 106 107 B 111 112

PROPERTY INFORMATION In the investigator's opinion, was the property maintained at or above average? (For research & analysis only; does not affect certificate.) Is this a single-family dwelling? If Yes, skip to Section B. Was random sampling used? If No, skip to Section B. Are there more than 20 dwelling units of similar construction and age built before 1960, or more than 13 dwelling units of similar construction and age built in 1960 or later? Were locations for sampling selected using random sampling in accordance with documented methodologies? Enter number of units sampled. Were all structures (units and common areas) constructed after 1959? CONFLICT OF INTEREST Was any investigator a property owner, or an immediate family member, agent or employee of a property owner? Was any investigator a lead company or associated with a certified lead company that is directly or beneficially owned, controlled or managed by the property owner, or by an immediate family member, agent or employee of the property owner? Was any investigator a person hired by or under contract with the property owner to manage or maintain the property owner's real property as directed by the property owner? Was any investigator a person who has been authorized by the property owner to manage or maintain the property owner's real property on the property owner's behalf? Was any investigator a person who has a financial interest in the laboratory results of the sampling or testing or in the determination of whether the property meets the registered leadfree property standard or the registered lead-safe property standard? Was the lead investigation performed in an unbiased, objective and impartial manner in accordance with s. HFS 163.40 and work practice standards under s. HFS 163.14, 163.41, or 163.42, as applicable? INVESTIGATION INFORMATION Enter the start date of the investigation. Were samples submitted to a laboratory for analysis? If No, skip to #125. Enter the date the laboratory report was received. Enter the name of the laboratory where samples were analyzed. Enter the end date of the investigation. Enter the certification number of each person involved in performing this lead investigation. Yes No Yes Yes Yes Yes Yes No No No No No

Yes Yes Yes

No No No

113 114 115

Yes Yes Yes

No No No

116

Yes

No

C 121 122 123 124 125 126

D 131 132 133 134

XRF Was an XRF used in this investigation? If No, skip to Section E. Enter XRF Manufacturer Enter XRF Model Enter XRF Serial Number Yes No

DPH 44011 (03/02) Page 4

135 136 137 138 139 140 141 142 E 151 152 153 F 161 162 163 164 165 166 167 G 171 172 173 174 175 176

Enter date source was last replaced Was the XRF calibrated per manufacturer's specifications? Was the XRF used according to the manufacturer's specifications? How many surfaces were tested using the XRF? Were any XRF readings inconclusive according to the manufacturer's specifications? If No, skip to Section E. How many surfaces had readings that were inconclusive? Were all surfaces with inconclusive XRF readings assumed to be lead-based paint? If Yes, skip to Section E. Were paint chip samples taken of surfaces with inconclusive readings? PAINT CHIP SAMPLES Were paint chip samples collected in this investigation? If No, skip to Section F. Were documented methodologies used to collect the paint chip samples? How many paint chip samples were collected? DUST WIPE SAMPLES Were dust wipe samples collected in this investigation? If No, skip to Section G. Were single-surface dust wipe samples collected? If No, skip to #165. Were documented methodologies used to collect the single-surface dust wipe samples? How many single-surface dust wipe samples were collected? Were composite dust wipe samples collected? If No, skip to Section G. Were documented methodologies used to collect the composite dust wipe samples? How many composite dust wipe samples were collected? SOIL SAMPLES Did the property owner request an evaluation of soil? If No, proceed to either the Lead-Free Inspection Information or Lead-Safe Investigation Information Form. Was bare soil present? If No, proceed to either the Lead-Free Inspection Information or LeadSafe Investigation Information Form. Were soil samples collected? Were documented methodologies used to collect the soil samples? How many soil samples were collected? Was the arithmetic mean (average) of the laboratory results for the soils equal to or greater than 2,000 parts per million? Yes No Yes Yes Yes Yes No No No No Yes Yes No No Yes Yes Yes No No No Yes Yes No No Yes Yes No No Yes No Yes Yes No No

DPH 44011 (03/02) Page 5

LEAD-FREE INSPECTION INFORMATION
Report status at the time of the lead-free inspection. A previous determination that paint is lead-free may be included in this lead-free inspection if the current investigator determines the process used to make the determination complies with the sampling and testing protocol under s. HFS 163.40, Wis. Adm. Code. Check boxes that apply and fill in appropriate information.

H 201

DWELLING UNITS For each dwelling unit tested, were all painted/coated floors with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated floors, answer "Yes", and go to 202. If No, skip to #203. Did any coating on a floor tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, were all doors and all door components with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated doors, answer "Yes", and go to 204. If No, skip to #205. Did any coating on a door component tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, were all interior stairways and all stair components with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated interior stairways or stair components, answer "Yes" and go to 206. If No, skip to #207. Did any coating on an interior stair component tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, were all windows and all window components with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated windows or window components, answer "Yes" and go to 208. If No, skip to #209. Did any coating on a window component tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, were all walls with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated walls, answer "Yes" and go to 210. If No, skip to #211. Did any coating on a wall tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, were all ceilings with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated ceilings, answer "Yes" and go to 212. If No, skip to #213. Did any coating on ceiling tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? For each dwelling unit tested, was all interior trim with a distinct paint history, including molding and baseboards, tested for the presence of lead-based paint? If there is no painted/coated interior trim, answer "Yes" and go to 214. If No, skip to #215. Did any coating on interior trim tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.06% lead by weight? Are the common areas covered by an existing lead-free certificate? If No, skip to Section I. Enter number for current lead-free certificate that covers the common areas. Skip to Section K. INTERIOR COMMON AREAS For interior common areas, were all components with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated components in interior common areas, answer "Yes" and go to 222. If No, skip to Section J. Did any coating on a component of an interior common area tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.05% lead by weight? Yes No Yes No

202 203

Yes Yes

No No

204 205

Yes Yes

No No

206 207

Yes Yes

No No

208 209

Yes Yes

No No

210 211

Yes Yes

No No

212 213

Yes Yes

No No

214 215 216 I 221

Yes Yes

No No

222

Yes

No

DPH 44011 (Rev. 03/02) Page 6

J 231

EXTERIOR COMMON AREAS Were all siding, facia and soffit systems with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated siding, facia or soffit systems, answer "Yes" and go to 232. If No, skip to #233. Did any coating on siding, facia or soffit systems tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.05% lead by weight? For exterior common areas, were all stairs, porches and decks with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated stairs, porches or decks, answer "Yes" and go to 234. If No, skip to #235. Did any coating on an exterior stair system, porch or deck tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.05% lead by weight? For exterior common areas, were all structures with a distinct paint that are associated with the property, such as an outbuilding or fence, tested for the presence of lead-based paint? If there are no painted/coated exterior structures, answer "Yes" and go to 236. If No, skip to #237. Did any coating on a structure tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.05% lead by weight? For exterior common areas, were all other components with a distinct paint history tested for the presence of lead-based paint? If there are no painted/coated components in exterior common areas, answer "Yes" and go to #238. If No, skip to Section K. Did any coating on a component of an exterior common area tested by XRF or paint chip sample have more than 0.7 milligrams lead per square centimeter or 0.05% lead by weight? REMOVAL OF PAINT OR PAINTED COMPONENTS Was any paint or painted component removed in the previous 12 months? Was the department's form signed by the property owner or the property owner's representative stating no paint or painted components were removed in the previous 12 months? If Yes, skip the rest of the questions. Is there a clearance report issued by a certified person after the most recent removal of paint or painted components? If Yes, respond to #244 and skip Section L. Enter name of company issuing the clearance report. CLEARANCE CONDUCTED DURING LEAD-FREE INSPECTION Was a visual inspection conducted of sites where interior paint or interior painted components had been removed? Were interior dust, debris, residue, or paint chips visible? Were any visible interior dust, debris, residue, or paint chips then removed? Was any interior removal of paint or painted components done in containment? For interior work conducted in containment, were all clearance dust wipe samples collected in accordance with HFS 163.14 (5) (c) 3. 'Location of sampling for work conducted in containment'? For interior work conducted without containment, were all clearance dust wipe samples collected in accordance with HFS 163.14 (5) (c) 4., 'Location of sampling for work conducted without containment'? Was the arithmetic mean (average) for all dust samples collected from floors less than 40 micrograms per square foot? Was the arithmetic mean (average) for all dust samples collected from interior windowsills less than 250 micrograms per square foot? Was the laboratory result for all dust samples collected from window troughs less than 800 micrograms per square foot? Was a visual inspection conducted of sites where exterior paint or exterior painted components had been removed? Were exterior dust, debris, residue, or paint chips visible? Yes Yes Yes Yes Yes No No No No No Yes Yes No No Yes No

232 233

Yes Yes

No No

234 235

Yes Yes

No No

236 237

Yes Yes

No No

238 K 241 242

Yes

No

243 244 L 251 252 253 254 255

Yes

No

256

Yes

No

257 258 259 260 261

Yes Yes Yes Yes Yes

No No No No No

DPH 44011 (03/02) Page 7

LEAD-SAFE INVESTIGATION INFORMATION
Report status at the time of the lead-safe investigation. A previous determination that paint is lead-free may be included in this leadsafe investigation if the current investigator determines the process used to make the determination complies with the sampling and testing protocol under s. HFS 163.40, Wis. Adm. Code. Check boxes that apply and fill in appropriate information.

M 301 302 N 311 312 313 314 315 316 317 318

VISUAL ASSESSMENT - SCOPE Was a visual assessment conducted of all dwelling units selected for investigation using documented methodologies? Was a visual assessment conducted of all exterior and interior common areas? VISUAL ASSESSMENT ­ GENERAL EXTERIOR Were lead-based paint chips visible on soil? Was lead-based paint (paint that had not been proven to be lead-free) present on any exterior building component? If No, skip to Section S. Were gutters and downspouts present? If No, skip to #315. Were gutters and downspouts functioning normally? Skip to #316. Was there evidence of damage to a lead-based painted surface due to a lack of gutters or downspouts? Were all lead-based painted exterior building components fully enclosed with durable material? If No, skip to #318. Did any enclosure show evidence of failing? If No, skip to Section S. Was there exterior evidence of ongoing water damage to lead-based painted surfaces, such as damage from an unrepaired water leak in the roof, gutter, downspout, foundation, plumbing, air conditioning or heating system? Was there evidence of mold, mildew, moisture or water damage to an exterior component where lead-based paint is present but no active leak? Did any substrate show visible evidence of defect, damage, decay or deterioration that might cause deteriorated paint? Was deteriorated lead-based paint detected on exterior building components below 5 feet from ground or floor level? Was deteriorated lead-based paint detected on exterior painted building components at a height above 5 feet from ground or floor level? If No, skip to Section O. Was the combined total area of all deteriorated lead-based paint for all exterior surfaces above 5 feet from ground or floor level more than 5 square feet? VISUAL ASSESSMENT ­ EXTERIOR FLOORS AND STAIRS IN SECURED AREAS In an area that is locked and secured against access by occupants (other than the property owner, property owner's family, agent or employee), was lead-based paint (paint that had not been proven to be lead-free) present on any exterior floor or stairs? If No, skip to Section P. Was all lead-based paint on these exterior floors and stairs entirely enclosed with durable material? If No, skip to #334. Did any enclosure of these exterior floors or exterior stairs show evidence of failing? If No, skip to Section P. Were all painted surfaces of these exterior floors and the traffic areas of these stair treads covered by carpeting or a durable material that protects them from abrasion? If yes, skip to Section P. Were all lead-based painted surfaces of these exterior floors and the traffic area of all stair treads protected by a topcoat that does not contain lead-based paint? If No, skip to Section P. Did the lead-free topcoat on any lead-based painted surface of these exterior floors show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Yes Yes No No

319 320 321 322 323 O 331

Yes Yes Yes Yes Yes

No No No No No

332 333 334

Yes Yes Yes

No No No

335

Yes

No

336

Yes

No

DPH 44011 (03/02) Page 8

P 341 342 343 344 345 346 Q 351 352 353 354 355 356 R 361

VISUAL ASSESSMENT ­ EXTERIOR FLOORS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any exterior floor (excluding stairs) of a dwelling unit or common area? If No, skip to Section Q. Was all lead-based paint on these exterior floors entirely enclosed with durable material? If No, skip to #344. Did any enclosure of these exterior floors show evidence of failing? If No, skip to Section Q. Were all painted surfaces of these exterior floors covered by carpeting or a durable material that protects the floors from abrasion? If yes, skip to Section Q. Were all lead-based painted surfaces of these exterior floors protected by a topcoat that does not contain lead-based paint? If No, skip to Section Q. Did the lead-free topcoat on any lead-based painted surface of these exterior floors show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? VISUAL ASSESSMENT ­ EXTERIOR STAIRS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any exterior stair of a dwelling unit or common area? If No, skip to Section R. Was all lead-based paint on these exterior stairs entirely enclosed with durable material? If No, skip to #354. Did any enclosure of these exterior stairs show evidence of failing? If No, skip to Section R Was all lead-based paint on the traffic area of the stair treads covered with a durable material or carpet that protects the tread from abrasion? If yes, skip to Section R. Were all lead-based painted surfaces of these exterior stair treads protected by a topcoat that does not contain lead-based paint? Did the lead-free topcoat on any lead-based painted traffic area of these exterior stair treads show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? Yes Yes Yes Yes Yes Yes No No No No No No Yes Yes Yes Yes Yes Yes No No No No No No

VISUAL ASSESSMENT ­ EXTERIOR PORCHES AND MISCELLANEOUS EXTERIOR HORIZONTAL SURFACES OF DWELLING UNITS AND COMMON AREAS Other than an exterior floor or stair, was lead-based paint (paint that had not been proven to be lead-free) present on any exterior porch component or any horizontal exterior surface? If No, skip to Section S. Was all lead-based paint on these exterior porch components and horizontal surfaces entirely enclosed with durable material? If No, skip to Section S. Did any enclosure of these exterior porch components or horizontal surfaces show evidence of failing? VISUAL ASSESSMENT ­ GENERAL INTERIOR Were lead-based paint chips visible on floors, stairways, windowsills, or window wells (troughs)? Was lead-based paint (paint that had not been proven to be lead-free) present on any interior component, including built-in cabinets? If No, skip to Section T. Were all painted interior components fully enclosed with durable material? If No, skip to #375. Did any enclosure show evidence of failing? If No, skip to Section T. Was deteriorated lead-based paint detected on any interior component? Did any substrate show visible evidence of defect, damage, decay or deterioration that might cause deteriorated paint? Was unkeyed plaster present beneath lead-based paint? Was there interior evidence of ongoing water damage to painted surfaces, such as damage from an active water leak that was not repaired? Was there evidence of mold, mildew, moisture or water damage to an interior component where lead-based paint is present but no active leak? Other than windows, doors, drawers, stairs or floors, was unprotected lead-based paint present on any interior friction surface? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Yes No

362 363 S 371 372 373 374 375 376 377 378 379 380

Yes Yes

No No

DPH 44011 (03/02) Page 9

T 381

VISUAL ASSESSMENT ­ INTERIOR FLOORS AND STAIRS IN LOCKED AND SECURED AREAS In an area that is locked and secured against access by occupants (other than the property owner, property owner's family, agent or employee), was lead-based paint (paint that had not been proven to be lead-free) present on any interior floor or stairs? If No, skip to Section U. Was all lead-based paint on these interior floors and stairs entirely enclosed with durable material? If No, skip to #384. Did any enclosure of these interior floors or interior stairs show evidence of failing? If No, skip to Section U. Were all painted surfaces of these interior floors and the traffic areas of these stair treads covered by carpeting or a durable material that protects them from abrasion? If yes, skip to Section U. Were all lead-based painted surfaces of these interior floors and the traffic area of all stair treads protected by a topcoat that does not contain lead-based paint? If No, skip to Section U. Did the lead-free topcoat on any lead-based painted surface of these interior floors show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? VISUAL ASSESSMENT ­ INTERIOR FLOORS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any interior floor (excluding stairs) of a dwelling unit or common area? If No, skip to Section V. Was all lead-based paint on these interior floors entirely enclosed with durable material? If No, skip to #394. Did any enclosure of these interior floors show evidence of failing? If No, skip to Section V. Were all painted surfaces of these interior floors covered by carpeting that protects the floors from abrasion? If yes, skip to Section V. Were all lead-based painted surfaces of these interior floors protected by a topcoat that does not contain lead-based paint? If No, skip to Section V. Did the lead-free topcoat on any lead-based painted surface of these interior floors show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? VISUAL ASSESSMENT ­ INTERIOR STAIRS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any interior stair of a dwelling unit or common area? If No, skip to Section W. Was all lead-based paint on these interior stairs entirely enclosed with durable material? If No, skip to #404. Did any enclosure of these interior stairs show evidence of failing? If No, skip to Section W. Were the traffic areas of all interior lead-based painted stair treads in a dwelling unit or common area covered with a durable material or carpet that protects the tread from abrasion? If yes, skip to Section W. Did lead-based painted traffic areas of interior stair treads in dwelling units and common areas have, at a minimum, a protective topcoat that does not contain lead-based paint? Did lead-based painted traffic areas of interior stair treads in dwelling units and common areas show evidence of abrasion, such as an obvious wear pattern or extensive scuffing? Yes Yes Yes Yes No No No No Yes Yes Yes Yes Yes Yes No No No No No No Yes No

382 383 384

Yes Yes Yes

No No No

385 386 U 391 392 393 394 395 396 V 401 402 403 404

Yes Yes

No No

405 406 W 411 412 413 414 415

Yes Yes

No No

VISUAL ASSESSMENT ­ DOORS OF INTERIOR BUILT-IN CABINETS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any door of an interior built-in cabinet of a dwelling unit or common area? If No, skip to Section X. Was all lead-based paint on these cabinet doors entirely enclosed with durable material? If No, skip to #414. Did any enclosure of these cabinet doors show evidence of failing? If No, skip to Section X. Was there evidence that the opening or shutting of any of these cabinet doors exposed paint to damage by the impact of the door striking another component? Was built-up paint present where it could be crushed by normal action of a cabinet door, such as on the hinge side of a door? Yes Yes Yes Yes Yes No No No No No

DPH 44011 (03/02) Page 10

416 X 421 422 423 424

Was there evidence of friction involving a lead-based paint surface of these cabinet doors, such as sticking or binding?

Yes

No

VISUAL ASSESSMENT ­ DRAWERS OF INTERIOR BUILT-IN CABINETS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any drawer of an interior built-in cabinet of a dwelling unit or common area? If No, skip to Section Y. Was all lead-based paint on these cabinet drawers entirely enclosed with durable material? If No, skip to #424. Did any enclosure of these cabinet drawers show evidence of failing? If No, skip to Section Y. Was there evidence that the opening or shutting of any of these cabinet drawers exposed paint to damage by the impact of the drawer striking another component, such as the face of the cabinet? Was built-up paint present where it could be crushed by normal action of a cabinet drawer? Was there evidence of friction involving a lead-based paint surface of a built-in cabinet drawer, such as sticking or binding? Was lead-based paint (paint that had not been proven to be lead-free) present on any interior or exterior door? If No, skip to Section Z. Was all lead-based paint on all interior and exterior doors entirely enclosed with durable material? If No, skip to #434. Did any enclosure of these doors show evidence of failing? If No, skip to Section Z. Was there evidence that the opening or closing of any interior or exterior door exposed paint to damage by the impact of the door striking another component? Was built-up paint present where it could be crushed by normal action of any door, such as on the hinge side of a door? Was there evidence of friction involving a lead-based paint surface of a door, such as sticking or binding? Yes Yes Yes Yes No No No No

425 426 Y 431 432 433 434 435 436 Z 441

Yes Yes

No No

VISUAL ASSESSMENT ­ INTERIOR AND EXTERIOR DOORS OF DWELLING UNITS AND COMMON AREAS Yes Yes Yes Yes Yes Yes No No No No No No

VISUAL ASSESSMENT ­ INTERIOR AND EXTERIOR WINDOW SYSTEM COMPONENTS OF DWELLING UNITS AND COMMON AREAS Was lead-based paint (paint that had not been proven to be lead-free) present on any interior or exterior component of a window system (including storm and screen windows)? If No, skip to Section ZA. Were weep holes present, open, and functional in all of these window systems that are designed to have weep holes? Was all lead-based paint on these window system components entirely enclosed with durable material? If No, skip to #445. Did any enclosure of these window system components show evidence of failing? If No, skip to Section ZA. Were window wells/troughs smooth and cleanable? Did windows function normally? Was built-up paint present on window systems where it might be crushed to create dust-lead or debris? Was glazing missing or did it have gaps? Were operable storm windows present and installed seasonally unless windows are doublepaned or not designed for storm windows. Was exposed lead-based paint present on any impact or friction surface of a window? DUST SAMPLING OF COMMON AREAS Were composite dust wipe samples collected in common areas? Were single-surface dust wipe samples collected from common areas? Was at least one floor surface or stair tread present in a common area? If No, skip to #457. Yes Yes Yes No No No Yes No

442 443 444 445 446 447 448 449 450 ZA 451 452 453

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

DPH 44011 (03/02) Page 11

454 455 456 457 458 459 460 ZB 461 462

Was at least one single-surface dust wipe sample taken from a floor or stair tread in a common area? Was at least one single-surface dust wipe sample taken from a floor where a child under age 6 would likely come into contact with dust? Using the lab results, was the arithmetic mean (average) for dust wipe samples collected from all floors less than 40 micrograms per square foot? Was at least one window present in a common area? If No, skip to Section ZB. Was at least one single-surface dust wipe sample taken from an interior windowsill in a common area? Was at least one single-surface sample taken from an interior windowsill where a child under age 6 would likely come into contact with dust? Using the lab results, was the arithmetic mean (average) for dust samples collected from all interior windowsills less than 250 micrograms per square foot? COMPOSITE DUST WIPE SAMPLING OF DWELLING UNITS Were composite dust wipe samples collected in dwelling units? If No, skip to Section ZC. Was at least one composite dust wipe sample taken for floors that consisted of 1 dust wipe from the main entryway and 3 dust wipes from rooms or areas where a child under age 6 would likely come into contact with dust? Were the lab results for all composite samples collected from floors less than 25 micrograms per square foot? Was at least one composite taken for windowsills that consisted of 4 dust wipes from windows most frequently operated or from rooms or areas where a child under 6 would likely come into contact with dust? If No, skip to #466. Was the lab result for all dust samples collected from interior windowsills less than 125 micrograms per square foot? Was at least one composite taken for window troughs/wells that consisted of 4 dust wipes from windows most frequently operated or from rooms or areas where a child under age 6 would likely come into contact with dust? Was the lab result for all dust samples collected from window wells/troughs less than 400 micrograms per square foot? SINGLE-SURFACE DUST WIPE SAMPLING OF DWELLING UNITS Were single-surface dust samples collected from dwelling units? If No, skip this Section. Were at least 4 separate, single-surface dust wipe samples taken from floors in rooms and areas where a child under age 6 would likely come into contact with dust? Was any single-surface dust wipe sample taken from a floor of a dwelling unit equal to or greater than 40 micrograms per square foot? Using the lab results, was the arithmetic mean (average) for all single-surface dust samples collected from all floors less than 40 micrograms per square foot? Was at least 1 single-surface dust wipe sample taken from a window trough of the window most frequently operated or where a child under 6 is likely to come into contact with dust? Was the lab result for all single-surface dust samples collected from all window troughs less than 800 micrograms per square foot? Excluding the window from which a trough/well sample was taken, were at least 4 separate, single-surface dust wipe samples taken from interior windowsills in rooms and areas where a child under age 6 would likely come into contact with dust? Was any single-surface dust wipe sample taken from an interior windowsill of a dwelling unit equal to or greater than 250 micrograms per square foot? Using the lab results, was the arithmetic mean (average) for all single-surface dust samples collected from all interior windowsills less than 250 micrograms per square foot?

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

Yes Yes

No No

463 464

Yes Yes

No No

465 466

Yes Yes

No No

467 ZC 471 472 473 474 475 476 477

Yes

No

Yes Yes Yes Yes Yes Yes Yes

No No No No No No No

478 479

Yes Yes

No No