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State Form 49150 - Indiana State Department Of Health - Notification Of Lead Abatement Activities Page 2

INDIANA STATE DEPARTMENT OF HEALTH

Notification of Lead Abatement Activities

LEAD AND HEALTHY HOMES PROGRAM

4/11

State Form 49150 (R7 / 4-11)

NOTIFICATION OF LEAD ABATEMENT ACTIVITIES

Type of Notification (check one):

Original

Revised*

Cancelled

Courtesy

*Must include copy of notification which is being revised

REMEMBER: EPA Renovator Certification is required for all non-abatement renovation activities in target housing and/or child-

occupied facilities [40 CFR 745].

II.

General Information (Identify owner, property address, lead activities contractor, lead inspector, risk assessor)

Property Owners Name: ________________________________________________________________________________________

Property Owners Address: _________________________________________________ City: _______________________________

State: _____ ZIP: ____________ Contact Name: _____________________________ Telephone: ___________________________

Lead Abatement Contractor: ___________________________________________________________________________________

Address: ___________________________________________________________ City: ___________________________________

State: _____ ZIP: ____________ Contact Name: ____________________________ Telephone: ____________________________

Indiana Contractor License Number: ___________________________________ Expiration Date

: _______________

(month, day, year)

FAX number: _______________________________ E-mail Address: __________________________________________________

Check here if you want a copy of the abatement notice letter mailed to you instead of faxed or sent by e-mail.

Lead Inspector or Risk Assessor Name: _________________________________________________________________________

Address: ____________________________________________________________________________________________________

City: __________________________________________________________ State: ________ ZIP: __________________________

Indiana License Number: __________________________________________ Expiration Date

: __________________

(month, day, year)

Telephone: ______________________________________

III. Type of Operations to be used on this site (check all that apply):

Interior

Wet Stripping

Encapsulation

Exterior

Dry Stripping

Enclosure

Emergency

IV. Procedures used to detect the Presence and Amount of Lead:

XRF Report

Paint Chip Analysis

Other: ___________________________________________________________

V. Approximate amount of lead-based paint affected:

VI. Scheduled dates of lead-based paint removal:

Linear Feet:

Start Date

(month, day, year)

Surface Area (square feet):

Completion Date

(month, day, year)

State Form 49150 - Indiana State Department Of Health - Notification Of Lead Abatement Activities Page 2

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