Form 49150 - Notification Of Lead Abatement Activities - Indiana Department Of Environmental Management
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2INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
NOTIFICATION OF LEAD ABATEMENT ACTIVITIES
State Form 49150 (R/8-99)
9 9 Original
9 9 Revised
9 9 Cancelled
9 9 Courtesy
I.
Type of Notification (check one):
* Must include copy of notification which is being revised
II. Facility Information (Identify owner, lead abatement contractor, inspector, risk assessor.)
Owner:
_________________________________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________City:________________________________
State: _________________ Zip:_____________
Contact: _______________________________
Telephone # ___________________________
Lead Abatement Contractor:
Address:____________________________________________________________________________________________City:____________________State: ________
Zip: ____________ Contact: ________________________ Telephone # ____________________ IN License #:________________________Exp. Date:____________
9 9
9 9
9 9
Hours of Operation:
________ A.M. to ________ P.M.
________ A.M. to ________ P.M.
All Shifts
Days of Operation
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Inspector: _________________________________________________________
Risk Assessor: (if used)_________________________________________________
Address: __________________________________________________________
Address: ___________________________________________________________
City: _______________________State:___________
City: __________________________State: ____________
IN License#: ________________________Expiration date:___________
IN License # ____________________Expiration date: ______________
Phone:
___________________________________________
Phone:
______________________________________________
III. Type of Operations (check all that apply) 9 9 Interior
9 9 Wet stripping
9 9 Encapsulation
9 9 Emergency
9 9 Exterior
9 9 Dry stripping
9 9 Enclosure
9 9 Soil Emergency
IV. Procedures including Analytical Methods, if appropriate, used to detect the Presence and Amount of Lead:
__________________________________________________________________________________________________________________________________________
V. Approximate Amount Of Lead Based Paint
VI. Scheduled Dates Of Lead Based Paint Removal
Linear Feet
Start Date
Surface Area (Square Feet)
Completion Date
VII. Child Occupied Facility Description ________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Building Name: ____________________________________________________________________________________________________________________________
Street Address: _______________________________________________________ City: _____________________ State: __________________ County:____________
Affected Component or Portion of Facility: ______________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Exact Activity Location: _____________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Building Size (SqFt) :__________________________________ # of Floors:____________ Age: _______
Present Use: ______________________________________________________ Prior Use: _______________________________________________________________
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