Mold Remediation Notification Form

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For Office Use Only:
Notification #:___________________
MOLD REMEDIATION NOTIFICATION FORM
DO NOT WRITE IN THIS BOX- FOR DEPARTMENT USE ONLY
Date Received:___/___/___
Source: ___Fax
___E-mail
___Mail
___Walk-in
SECTION 1: TYPE OF NOTIFICATION
TYPE OF NOTIFICATION: (Select one and fill in the requested information)
ORIGINAL: The DSHS Central Office was notified by:
Fax
E-mail
Hand Delivery
Mail
Date sent: ___/___/___ Time sent: _________________
a.m.
p.m.
AMENDMENT No.____ OR
CANCELLATION
Amendment/Cancellation Notification Required Information:
• • • • Was the Environmental Health Notifications Group (EHNG) notified by phone between 8:00 a.m. and 5:00 p.m. Central
Time of any project date changes or cancellation prior to the original start and/or original stop date?
Yes
No.
• • • • If yes, provide the name of the person you spoke with:
________________________________________________
• • • • Was the original amended notification faxed/e-mailed/overnight-mailed within 24 hours of the phone call?
Yes
No.
Date: _____/_____/_____
Time: __________
a.m.
p.m.
Additional Required Notice for Date Changes Less Than 5 Days from Original Start/Stop Date:
• • • • Was the appropriate Regional Office notified by e-mail/phone between 8:00 a.m. and 5:00 p.m. Central Time of any project
date changes or cancellation prior to the original start and/or original stop date?
Yes
No
• • • • If yes, provide the name of the person you spoke with: _____________________________________________________
Date: ___/___/___ Time: _____________________
a.m.
p.m.
• • • • Was a copy of the amended notification faxed/e-mailed/overnight-mailed to the appropriate Regional Office within 24 hours
of the phone call?
Yes
No.
• • • • Give a description of the reason for this amendment or cancellation:___________________________________________
___________________________________________________________________________________________________________________________
EMERGENCY
• • • • Was emergency request made to the Regional Office or (EHNG) by phone?
Yes
No
• • • • If yes, provide the DSHS reference number:_________________ and name of the person you spoke with:
_____________________________________ Date: ___/___/___ Time: __________
a.m.
p.m.
• • • • Describe the reason for emergency remediation: ___________________________________________________________
___________________________________________________________________________________________________
(x)
AMENDMENTS: You must complete the entire form and mark the appropriate check box(es) along the left-hand side of form below to
Below if
indicate amended information.
Amended
FACILITY INFORMATION
1. Facility Location/Description of Area
……. Facility/Residence Name:______________________________________________________________________________
……. Physical Address:____________________________________________________________________________________
……. County:_____________________ City:___________________________________ Zip:__________________________
……. Facility Contact Person: _____________________________________ Phone #: (
)____________________________
……. Description of area/room number:________________________________________________________________________
___________________________________________________________________________________________________
……. Area of mold to be remediated: ______________________________________ Number of floors:_____________________
2. Type of Facility (Select one)
…….
Owner-occupied Residential Dwelling Unit
Other
WORK SCHEDULE/DESCRIPTION OF WORK TO BE CONDUCTED
1. Scheduled dates of mold remediation:
……. Start date: ___/___/___ and Stop date: ___/___/__
……. Work days:
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Sun.
……. Working hours: ___________________
a.m.
p.m. to ______________________
a.m.
p.m.
2. Description of work to be conducted
……. Description of mold remediation to be conducted:___________________________________________________________
____________________________________________________________________________________________________________________________
Mold Notification EF18-12144 Rev. 5/07

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