Quarterly Report Form - Arkansas Department Of Health Lead-Based Paint Program

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Arkansas Department of Health

Lead-Based Paint Program

4815 West Markham Street, Mail Slot 32 ● Little Rock, Arkansas 72205-3867 ● Telephone (501) 671-1472

Quarterly Report

Year:

☐

January-March

☐

April-June

☐

July-September

☐

October-December

☐

No LBP Activity this quarter

Activity

Date/Property

Location Type*

Method

Inspection/RA Results

RA Guidance

☐Inspection

☐THS

☐Paint Chip Samples

☐Yes☐No

☐Abatement

Date: ___________________________

Interior LBP Found

☐Risk Assessment

☐THM

☐Dust Wipes

☐Yes☐No

☐Interim Control

Exterior LBP Found

Address: _________________________

☐Lead Hazard Screen

☐Soil Samples

☐Yes☐No

☐No Action

Units: _____

Dust Lead Hazard Found

_______________________________

☐Clearance Testing

☐COF

☐XRF

☐Yes☐No

Soil LBP Found

City, Zip: _________________________

☐O: _____________

☐Pass ☐Fail

☐Inspection

☐THS

☐Paint Chip Samples

☐Yes☐No

☐Abatement

Interior LBP Found

Date: ___________________________

☐Risk Assessment

☐THM

☐Dust Wipes

☐Yes☐No

☐Interim Control

Exterior LBP Found

Address: _________________________

☐Lead Hazard Screen

Units: _____

☐Soil Samples

☐Yes☐No

☐No Action

Dust Lead Hazard Found

_______________________________

☐COF

☐Clearance Testing

☐XRF

☐Yes☐No

Soil LBP Found

City, Zip: _________________________

☐O: _____________

☐Pass ☐Fail

☐Inspection

☐THS

☐Paint Chip Samples

☐Yes☐No

☐Abatement

Date: ___________________________

Interior LBP Found

☐Risk Assessment

☐THM

☐Dust Wipes

☐Yes☐No

☐Interim Control

Exterior LBP Found

Address: _________________________

☐Lead Hazard Screen

☐Soil Sample

☐Yes☐No

☐No Action

Units: _____

Dust Lead Hazard Found

_______________________________

☐COF

☐Clearance Testing

☐XRF

☐Yes☐No

Soil LBP Found

City, Zip: _________________________

☐O: _____________

☐Pass ☐Fail

☐Inspection

☐THS

☐Paint Chip Samples

☐Yes☐No

☐Abatement

Date: ___________________________

Interior LBP Found

☐Risk Assessment

☐THM

☐Dust Wipes

☐Yes☐No

☐Interim Control

Exterior LBP Found

Address: _________________________

☐Lead Hazard Screen

☐Soil Samples

☐Yes☐No

☐No Action

Units: _____

Dust Lead Hazard Found

_______________________________

☐COF

☐Clearance Testing

☐XRF

☐Yes☐No

Soil LBP Found

City, Zip: _________________________

☐O: _____________

☐Pass ☐Fail

☐Inspection

☐THS

☐Paint Chip Samples

☐Yes☐No

☐Abatement

Date: ___________________________

Interior LBP Found

☐Risk Assessment

☐THM

☐Dust Wipes

☐Yes☐No

☐Interim Control

Exterior LBP Found

Address: _________________________

☐Lead Hazard Screen

☐Soil Samples

☐Yes☐No

☐No Action

Units: _____

Dust Lead Hazard Found

_______________________________

☐COF

☐Clearance Testing

☐XRF

☐Yes☐No

Soil LBP Found

City, Zip: _________________________

☐Pass ☐Fail

☐O: _____________

*THS = Target Housing: Single Family Dwelling; THM = Target Housing: Multi-Unit Dwelling; COF = Child Occupied Facility; O = Other

I, ______________________________, affirm this form reflects all LBP activities performed during the indicated time period by the undersigned certificate

holder and the direction of the below mentioned state licensed firm.

Signature

Date

Certificate Number

Licensed Firm

Page _______ of________