State of Maine Environmental Lead Inspection Summary Form Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 Revised 2015 TEL (207) 287-2651 FAX (207) 287-6220 Property Information: Physical Address: Apt #: City: Maine Zip: Property Owner: Owner Mailing Address: City: Zip: Telephone #: Housing Type: Private Rental Child Building Age: Number of Rooms: If Rental, Number of Units in Building: Any Renovations Within Past 6 Months: Yes No Lead Inspector Information: Lead Inspector Name: ME Certification #: Company Name: Company Mailing Address: City: State: Zip: Telephone #: XRF Make & Serial Number: ME Radioactive Materials License #: Lead Inspection Information: Lead Inspection Date: Was lead-based paint detected: Yes No If yes, was lead-based paint on: Interior Exterior Common Areas Other If yes, were lead hazards identified: Yes No Interior Exterior Common Areas Other Additional samples collected: Paint Chip Dust Water Soil Sample results: Was a Certificate: issued: Yes No If yes, what is the expiration date: “Lead-Safe Lead Abatement Information: Does the owner of the building plan abatement of lead-based substances: Yes No N/A If yes, will abatement be performed by: Owner Lead Abatement Contractor Undecided Comments:
State of Maine Department of Environmental Protection Lead & Asbestos Hazard Prevention Program 17 State House Station, Augusta, ME 04333 TEL (207) 287-2651 FAX (207) 287-6220 Environmental Lead Inspection Summary Form Revised 2015 Property Information: Physical Address: Apt #: City: Maine Zip: Property Owner: Owner Mailing Address: City: Zip: Telephone #: Housing Type: Private Rental Child Building Age: Number of Rooms: If Rental, Number of Units in Building: Any Renovations Within Past 6 Months: Yes No Lead Inspector Information: Lead Inspector Name: ME Certification #: Company Name: Company Mailing Address: City: State: Zip: Telephone #: XRF Make & Serial Number: ME Radioactive Materials License #: Lead Inspection Information: Lead Inspection Date: Was lead-based paint detected: Yes No If yes, was lead-based paint on: Interior Exterior Common Areas Other If yes, were lead hazards identified: Yes No Interior Exterior Common Areas Other Additional samples collected: Paint Chip Dust Water Soil Sample results: Was a “Lead-Safe Certificate: issued: Yes No If yes, what is the expiration date: Lead Abatement Information: Does the owner of the building plan abatement of lead-based substances: Yes No N/A If yes, will abatement be performed by: Owner Lead Abatement Contractor Undecided Comments:
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