Cdph Form 8552 - Lead Hazard Evaluation Report
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1State of California—Health and Human Services Agency
California Department of Public Health
LEAD HAZARD EVALUATION REPORT
Section 1 — Date of Lead Hazard Evaluation _____________________
Section 2 — Type of Lead Hazard Evaluation (Check one box only)
Lead Inspection
Risk assessment
Clearance Inspection
Other (specify) _____________________________
Section 3 — Structure Where Lead Hazard Evaluation Was Conducted
Address [number, street, apartment (if applicable)]
City
County
Zip Code
Construction date (year)
Type of structure
Children living in structure?
of structure
Multi-unit building
School or daycare
Yes
No
Single family dwelling
Other____________
Don’t Know
Section 4 — Owner of Structure (if business/agency, list contact person)
Name
Telephone number
Address [number, street, apartment (if applicable)]
City
State
Zip Code
Section 5 — Results of Lead Hazard Evaluation (check all that apply)
No lead-based paint detected
Intact lead-based paint detected
Deteriorated lead-based paint detected
Lead-contaminated soil found
Other
No lead hazards detected
Lead-contaminated dust found
____________________
Section 6 — Individual Conducting Lead Hazard Evaluation
Name
Telephone number
Address [number, street, apartment (if applicable)]
City
State
Zip Code
CDPH certification number
Signature
Date
Name and CDPH certification number of any other individuals conducting sampling or testing (if applicable)
Section 7 — Attachments
A. A foundation diagram or sketch of the structure indicating the specifc locations of each lead hazard or presence of
lead-based paint;
B. Each testing method, device, and sampling procedure used;
C. All data collected, including quality control data, laboratory results, including laboratory name, address, and phone number.
First copy and attachments retained by inspector
Third copy only (no attachments) mailed or faxed to:
Second copy and attachments retained by owner
California Department of Public Health
Childhood Lead Poisoning Prevention Branch Reports
850 Marina Bay Parkway, Building P, Third Floor
Richmond, CA 94804-6403
Fax: (510) 620-5656
CDPH 8552 (6/07)
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