Inspector/risk Assessor - Lead-Based Activity Quarterly Report Form - Oklahoma Department Of Environmental Quality

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Inspector/Risk Assessor
Lead-Based Paint Activity Quarterly Report
Qtr 2 Apr-Jun 2015
Qtr 3 Jul-Sep 2015
Qtr 4 Oct-Dec 2015
Qtr 1 Jan-Mar 2016
No Lead-Based Paint Activity performed this quarter.
(Due Jul 10th)
(Due Oct 10th)
(Due Jan 10th)
(Due Apr 10th)
Note: Choose a report quarter at the left; sign and date at the bottom.
Note: Select only one report period. A separate, signed report is required for each quarter.
Date/Property
Location Type (Choose one)
Activity (Choose One)
Methodology
LBP Results
XRF
Interior LBP found
Target Housing: Single Family Dwelling
Inspection
Activity Date:______________
Yes
No
Risk Assesment
Target Housing: Multi-Unit Dwelling
Chip Sampling
Exterior LBP found
Date Built: (Do Not Use 'Unknown'): ___________
Yes
No
(# of Units________)
Hazard Screen
Dust Sampling
Dust Lead Hazard found
Address:_________________________________
Child-Occupied Facility
Yes
No
Clearance Testing Pass / Fail
Soil Sampling
Soil Lead Hazard found
Other:
Other:
City/ZIP:________________________________
Yes
No
Target Housing: Single Family Dwelling
Inspection
XRF
Interior LBP found
Activity Date:______________
Yes
No
Target Housing: Multi-Unit Dwelling
Risk Assesment
Chip Sampling
Exterior LBP found
Date Built: (Do Not Use 'Unknown'): ___________
Yes
No
(# of Units________)
Hazard Screen
Dust Sampling
Dust Lead Hazard found
Address:_________________________________
Child-Occupied Facility
Yes
No
Clearance Testing Pass / Fail
Soil Sampling
Soil Lead Hazard found
Other:
Other:
City/ZIP:________________________________
Yes
No
Target Housing: Single Family Dwelling
Inspection
XRF
Interior LBP found
Activity Date:______________
Yes
No
Risk Assesment
Target Housing: Multi-Unit Dwelling
Chip Sampling
Exterior LBP found
Date Built: (Do Not Use 'Unknown'): ___________
Yes
No
(# of Units________)
Hazard Screen
Dust Sampling
Dust Lead Hazard found
Address:_________________________________
Child-Occupied Facility
Yes
No
Clearance Testing Pass / Fail
Soil Sampling
Soil Lead Hazard found
Other:
City/ZIP:________________________________
Other:
Yes
No
Target Housing: Single Family Dwelling
Inspection
XRF
Interior LBP found
Activity Date:______________
Yes
No
Risk Assesment
Target Housing: Multi-Unit Dwelling
Chip Sampling
Exterior LBP found
Date Built: (Do Not Use 'Unknown'): ___________
Yes
No
(# of Units________)
Hazard Screen
Dust Sampling
Dust Lead Hazard found
Address:_________________________________
Child-Occupied Facility
Yes
No
Clearance Testing Pass / Fail
Soil Sampling
Soil Lead Hazard found
Other:
Other:
City/ZIP:________________________________
Yes
No
Target Housing: Single Family Dwelling
Inspection
XRF
Interior LBP found
Activity Date:______________
Yes
No
Risk Assesment
Target Housing: Multi-Unit Dwelling
Chip Sampling
Exterior LBP found
Date Built: (Do Not Use 'Unknown'): ___________
Yes
No
(# of Units________)
Hazard Screen
Dust Sampling
Dust Lead Hazard found
Address:_________________________________
Child-Occupied Facility
Yes
No
Clearance Testing Pass / Fail
Soil Sampling
Soil Lead Hazard found
Other:
Other:
City/ZIP:________________________________
Yes
No
I affirm this form truly reflects all LBP activities performed during the indicated time period by the undersigned certified LBP contractor.
PLEASE SEND TO THIS ADDRESS:
Department of Environmental Quality
Name:______________________________________
Date______________________
Attn: LBP Staff
(Please print clearly)
P.O. Box 1677
Oklahoma City, OK 73101-1677
Signature:___________________________________
Certification#_______________
DEQ Form #110-502
Page ____ of ____
(Please print clearly)
Revised 1/9/06

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