Lead Activity Declaration - Buildings, Safety Engineering And Environmental Department


Lead Activity Declaration
Buildings, Safety Engineering and Environmental Department
Coleman Alexander Young Municipal Center
2 Woodward Avenue, Suite 412
Detroit, Michigan 48226
This form must be completed by a State of Michigan licensed lead professional and submitted to the City of Detroit’s
Buildings, Safety Engineering and Environmental Department, Property Maintenance Division. Include the following
reports: Lead Based Paint Inspection; Lead Based Paint Risk Assessment; Remediation and Clearance Summary; and all
related laboratory results must be submitted to complete reporting requirements .
Subject Property Location: __________________________________________________________Detroit, MI 48________
Risk Assessors’ Name: ______________________________ Phone #___________________ State Certification # _________
Risk Assessors’ Address: _____________________________________
Company Name: ________________________________________________________Phone # _________________________
Company Address (if different): ________________________________
Property Owners’ Name: _________________________________________________ Phone # _________________________
Property Owners’ Address: ____________________________________
zip ______
Date(s) of Lead Inspection: ________________________ Date(s) of Lead Hazard Assessment: ________________________
Were lead based paint hazards identified? ___ NO. ___ YES. If yes, indicate what type(s): ___ paint ___dust
Were potential lead based paint hazards identified? ____ NO____YES
Was soil sampled? ____ NO ____ YES. If yes, indicate what type(s): ___play area ___drip-line/foundation ___vegetable garden
Other (describe) ___________________________________________________________________________________________
Indicate why soil was not sampled: ____________________________________________________________________________
Note: If soil conditions cannot be ascertained risk assessor must return to site and evaluate the need for soil sampling.
When soil conditions are determined, the risk assessor must submit an addendum report with their findings.
Lead-based paint detection technique used (check one): ___ paint chip samples
___ XRF (serial # ___________)
The undersigned hereby acknowledges that the information provided herein and related reports are complete, accurate and
he undersigned also accepts full and irrevocable responsibility for the validity of the information provided, legal and
regulatory, in accordance with all federal, state, and local requirements. Work Practice Standards adopted by the Sate of
Michigan for Lead Hazard Control for a Lead inspection, R325.99403, and for a Risk Assessment, R325.99404, must be
adhered to.
Risk Assessor’s State Certification #____________________________________ Expiration date:________________________
Complete and attach additional copies of this form, as needed, for complete reporting.


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