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INDIANA STATE DEPARTMENT OF HEALTH

Notification of Lead Abatement Activities

LEAD AND HEALTHY HOMES PROGRAM

4/11

State Form 49150 (R7 / 4-11)

VII. Property Description:

Child-occupied Facility

Target Housing

Other: _________________________________

Work Site Address: ________________________________________ City: ____________________ , IN Zip code: _____________

Affected component or portion of facility: _________________________________________________________________________

_____________________________________________________________________________________________________________

Exact activity location(s): _______________________________________________________________________________________

_____________________________________________________________________________________________________________

Number of floors: ___________ Age of structure: _________________ Present use: _____________________________________

VIII. Description of planned activity work to be performed and methods to be used:

_____________________________________________________________________________________________________________

IX. Description of work practices and engineering controls to be used to comply with this rule:

_____________________________________________________________________________________________________________

X. Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead hazard and warrants

immediate action: _____________________________________________________________________________________________

_____________________________________________________________________________________________________________

XI. For Emergencies Only:

Explanation of how the event caused a lead hazard and warranted immediate action: _________________________________

______________________________________________________________________________________________________________

XII.

I hereby certify that the information in this notification is correct and that I will only use Indiana-licensed workers and project

supervisors, to implement this lead abatement activity, which have been trained under 410 IAC 32; 40 CFR 745. The trained

individual(s) along with evidence that the required training was accomplished shall be available at the job site during actual

work hours.

______________________________________________________

_____________________________________________________

Owner/operator (signature)

Date (month, day, year)

______________________________________________________

_____________________________________________________

Owner/operator (printed)

Affiliation

State Form 49150 - Indiana State Department Of Health - Notification Of Lead Abatement Activities Page 3