NOTIFICATION OF LEAD ABATEMENT ACTIVITIES State Form 49150 (R6 / 10-10) Approved by State Board of Accounts, 2010 INDIANA STATE DEPARTMENT OF HEALTH INDIANA STATE DEPT. OF HEALTH Lead and Healthy Homes Program 2 N. Meridian St., 5J Indianapolis, IN 46204 Phone: (317) 233-1250 http://www.in.gov/isdh/19124.htm INSTRUCTIONS: 1. This State form, 49150 must be used to notify of lead abatement activities pursuant to 410 IAC 32. If accessing this form on-line at the URL listed above, you may print the blank form and fill it out by hand for submission with original signatures. 2. Submit one notification form for each address for which you are seeking approval. The cost is $ 50.00 per notification. 3. Please type or print in ink. 4. Return this form, required addenda, and check or money order made payable to "ISDH Lead and Healthy Homes Program" by mail to: Cashier’s Office Indiana State Department of Health PO Box 7236 Indianapolis, Indiana 46207 5. Notification is only required when a project’s activities are designed to permanently eliminate Lead based paint hazards. 6. Section I: Type of Notification-410 IAC 32-4-6 A. If this is the original notice, please check the appropriate space on the notification form. B. If this is a revised notice, please check the appropriate space on the notification form. The revised notice must be postmarked at least 5 working days or delivered at least 2 working days before the start date of lead abatement activity. Facsimiles will be accepted by the ISDH. C. If this is a cancelled notice, please check the appropriate space on the notification form. E. 7. All revisions must include a copy of the notice being revised. D. Courtesy Notification. Section II: Facility Information-410 IAC 32-4-6(1)(D) A. Either the owner or operator must submit the notice. B. The owner means the individuals(s) who own the property or lease the property. C. The operator means the lead abatement contractor. D. Specify the name, address, telephone number, Indiana license number and license expiration date, of the: 1. 8. lead abatement contractor; and 2.the risk assessor or lead inspector who conducted the inspection prior to abatement Section III: Type of Operation-410 IAC 32-4-6(2)(D) A. 9. Refer to the definitions of encapsulation, enclosure and emergency abatement in 410 IAC 32-1. B. Owner/Operator must also complete Section XIII of notification form. Section IV: Procedures, Including Analytical Methods Used To Detect the Presence and Amounts of Lead Based Paint.-410 IAC 32-46(2)(F) 10. Section V: Approx. Amounts of Lead To Be Removed - 410 IAC 32-4-6(2)(G) Specify the amount of Lead Based paint to be removed in terms of linear feet or square feet on facility components. 11. Section VI: Scheduled Dates of Lead Based Paint Removal - 410 IAC 32-4-6(2)(I) This means the actual start and end date of lead-based paint hazard remediations in the work area. 12. Section VII: Facility Description - 410 IAC 32-4-6(2)(E) and (H) Provide enough detail that an unfamiliar inspector can find the abatement without asking anyone. 13. Section VIII: Description of planned activity work to be performed and methods to be employed - 410 IAC 32-4-6(2)(J) Briefly describe the methods to be used such as encapsulation, enclosure, heat scrapping, etc..., list the affected facility components such as doors, windows, and floors. 14. Section IX: Description of work practice and engineering controls to be used - 410 IAC 32-4-6(2)(K) Examples of work practices and engineering controls to prevent lead emissions at the site would include: the use of water or wetting agents, containments, and negative air units during removal; daily clean up, placing waste into leak tight containers and secure storage. 15. Section X: Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead based hazard and warrants immediate action. 410 IAC 32-4-6(2)(O) Procedures could include any steps taken to immediately minimize exposure potential. A notification would need to be given as early as possible, but not later than the following work day. 16. Section XI: Emergency lead abatement- 410 IAC 32-4-6(2)(O) Specify: 1. The date that the emergency occurred, 2. a description of the sudden unexpected event, and 3. an explanation of how the event causes a lead-based paint hazard and warrants immediate action. 17. Section XII: Certification Statement and Signature by Owner/Operator-410 IAC 32-4-6(2)(M) Self-explanatory. American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49150 (R6 / 10-10) Notification of Lead Abatement Activities 10/10 NOTIFICATION OF LEAD ABATEMENT ACTIVITIES I. Type of Notification (check one): Original Revised* Cancelled Courtesy *Must include copy of notification which is being revised REMEMBER: EPA Renovator Certification is required for all non-abatement renovation activities in target housing and/or childoccupied facilities [40 CFR 745]. II. General Information (Identify owner, property address, lead activities contractor, lead inspector, risk assessor) Property Owners Name: ________________________________________________________________________________________ Property Owners Address: _________________________________________________ City: _______________________________ State: _____ ZIP: ____________ Contact Name: _____________________________ Telephone: ___________________________ Lead Abatement Contractor: ___________________________________________________________________________________ Address: ___________________________________________________________ City: ___________________________________ State: _____ ZIP: ____________ Contact Name: ____________________________ Telephone: ____________________________ Indiana Contractor License Number: ___________________________________ Expiration Date (month, day, year): _______________ FAX number: _______________________________ E-mail Address: __________________________________________________ Check here if you want a copy of the abatement notice letter mailed to you instead of faxed or sent by e-mail. Lead Inspector or Risk Assessor Name: _________________________________________________________________________ Address: ____________________________________________________________________________________________________ City: __________________________________________________________ State: ________ ZIP: __________________________ Indiana License Number: __________________________________________ Expiration Date (month, day, year): _________________ Telephone: ______________________________________ III. Type of Operations to be used on this site (check all that apply): Interior Wet Stripping Encapsulation Exterior Dry Stripping Enclosure Emergency IV. Procedures used to detect the Presence and Amount of Lead: XRF Report Paint Chip Analysis Other: ___________________________________________________________ V. Approximate amount of lead-based paint affected: VI. Scheduled dates of lead-based paint removal: Linear Feet: Start Date (month, day, year): Surface Area (square feet): Completion Date (month, day, year): American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 49150 (R6 / 10-10) VII. Property Description: Child-occupied Facility Notification of Lead Abatement Activities 10/10 Target Housing Other: _________________________________ Work Site Address: ________________________________________ City: ____________________ , IN ZIP code: _____________ Affected component or portion of facility: _________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Exact activity location(s): _______________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Number of floors: ___________ Age of structure: _________________ Present use: _____________________________________ VIII. Description of planned activity work to be performed and methods to be used: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ IX. Description of work practices and engineering controls to be used to comply with this rule: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ X. Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead hazard and warrants immediate action: _____________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ XI. For Emergencies Only: Explanation of how the event caused a lead hazard and warranted immediate action: _________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ XII. I hereby certify that the information in this notification is correct and that I will only use Indiana-licensed workers and project supervisors, to implement this lead abatement activity, which have been trained under 410 IAC 32; 40 CFR 745. The trained individual(s) along with evidence that the required training was accomplished shall be available at the job site during actual work hours. ______________________________________________________ _____________________________________________________ Owner/operator (signature) Date (month, day, year) ______________________________________________________ _____________________________________________________ Owner/operator (printed) Affiliation American LegalNet, Inc. www.FormsWorkFlow.com