C.M.R. 06, 096, ch. 424, app 096-424-F
State of Maine Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 TEL (207) 287-7688 FAX (207) 287-6220 | Environmental Lead Inspection/Risk Assessment Summary Form Due to Department within 30 days of inspection Revised 2020 |
Property Information: Physical Address: Apt #: City: State: Maine Zip: Property Owner: Owner Mailing Address: City: State: Zip: Telephone #: Housing Type: Private Rental Child Care Other Building Age: Number of Rooms: If Rental, Number of Units in Building: Any Renovations Within Past 6 Months: Yes No | |
Lead Inspector Information: Risk assessor/Lead Inspector Name: ME Certification #: Company Name: Company Mailing Address: City: State: Zip: Telephone #: XRF Make & Serial Number: ME Radioactive Materials License #: | |
Lead Inspection Information: Lead Inspection Date: Was lead-based paint detected: Yes No If yes, was lead-based paint on: Interior Exterior Common Areas Other If yes, were lead-based paint hazards identified: Yes No Interior Exterior Common Areas Other Additional samples collected: Paint Chip Dust Water Soil Sample results: Was a "Lead-Safe Certificate: issued: Yes No If yes, what is the expiration date: | |
Lead Abatement Information: Does the owner of the building plan abatement of lead-based substances: Yes No N/A If yes, will abatement be performed by: Owner Lead Abatement Contractor Undecided | |
Comment: | |
Signature: Risk assessor/Lead Inspector Signature Date Print Name: | |
C.M.R. 06, 096, ch. 424, app 096-424-F