Facility/site Essential Maintenance Practices Compliance Check Form
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1Page 1 of ____
Date:
Case/Project #:
Official
Use Only
Time:
108 Cherry Street – PO Box 70
Agency of Human Services
Burlington, VT 05402-0070
802-865-7786
Department of Health
[phone]
802-863-7483
Environmental Health
[fax]
Essential Maintenance Practices Compliance Check Form
Facility/Site Location Name:
Physical Address (No P.O. Box):
Physical City:
State
Zip Code:
VT
General/Abatement Contractor Name:
Mailing Address:
Mailing City:
State
Zip Code:
Office Telephone # or Cell phone #:
Fax #:
Email Address:
Owner/Agent Name:
Mailing Address:
Mailing City:
State
Zip Code:
Office Telephone # or Cell phone #:
Fax #:
Email Address:
Inspector/Consultant Name:
Mailing Address:
Mailing City:
State
Zip Code:
Office Telephone # or Cell phone #:
Fax #:
Email Address:
Reason for Compliance Check:
Number of Units
Total Number of Units
Inspected:
at Property:
Initial
Follow-up
(Last Inspection Date: _________ )
Random Check
-
_______________
Tip or Complaint
For
Cause
Other
Type of Property:
Inspection Type and Date Built:
Conducting Inspection:
_______
Lead
Health Officer
Other
Daycare
Rental
Private
Commercial
_________
Asbestos
(year built)
VDH Staff
_____________
Public Building
Other
Vermont Essential Maintenance Practices
• ‘Prevent Lead Poisoning’ poster posted
• Window well inserts in all wooden windows
Yes: Common Area(s) Each Apartment
Yes
Not Applicable: Windows are vinyl metal or other
No
No: Windows without inserts, location(s): ________________________
• Surfaces and fixtures free of deteriorated paint
(Take photos and document facts on a separate page, if needed)
2
Yes, greater than 1 ft
of deteriorated paint on an:
No
Interior surface, Location(s):
Exterior surface, Location(s):
• EPA ‘Protect Your Family From Lead’ pamphlet given to tenants
Yes
No:
Tenant Reports that he/she did not receive pamphlet
Tenant unavailable Unknown
• Evidence of Prohibited Practices
Yes (check all that apply – take photos and document facts on a separate page)
No
Burning
Water Blasting
Dry Scraping
Power Sanding
Sandblasting
Other: _______________________
State Certification and Federal Disclosure
• Tenant notification in lease
• Notification of renovation
• EMP Name:
• EMP #:
Yes
No
Yes (see above for contractor information) No
Overall Findings and Required Corrections (see photos and additional pages with findings and corrective actions)
Required Compliance Date:
Follow-up Check Date Set:
Referred to Other State Agency/Department or Other Organization:
Yes
No
Contractor Signature: ___________________ Date: _________
Inspector Signature: ______________________ Date: _______
Owner Signature: _____________________ Date: _________
THO/VDH Signature: ______________________ Date: _______
8.2015
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