**Lead Hazard Evaluation Notice**

Property Address: Date:

Evaluation Completed (circle one): Paint Inspection Paint Testing Risk
Assessment

Summary of Results:

\_\_\_\_ No lead-based paint or lead-based paint hazards were found.

\_\_\_\_ Lead-based paint and/or lead-based paint hazards were found.
See attachment for details.

Person who prepared this notice:

Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Company: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City & State: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Zip: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Phone \# \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**If you have any questions please call Syracuse Lead Hazard Control
Program at 448-8710**

**Lead-Based Paint**

**Risk Assessment / Inspection Report**

For The Dwelling Located at:

123 Any Street

Syracuse, New York

Prepared For:

Ms. Betsy Mokrzycki, Program Manager

City of Syracuse Lead Program

201 East Washington Street

Syracuse, NY 13202

March 17, 2004

**EXPIRATION DATE: March 10, 2005**

**GENERAL INFORMATION**

The City of Syracuse Lead Program (USEPA Firm NY-07-022006-973)
conducted a risk assessment / inspection for lead-based paint hazards at
123 Any Street in Syracuse, New York on March 10, 2004. John Doe (USEPA
Risk Assessor NY-02-022004-789) and Jane Doe (USEPA Risk Assessor
NY-05-022005-456) performed this Lead Based Paint Risk Assessment /
inspection. The sample analysis was performed by: 123 Laboratories, Inc
at 2345 W. Cary Street, Richmond, VA and can be reached by phone at
(888)444-5555.

OWNER INFORMATION

+------------------+---------------------------+----------+-----------+
| **Address**      | **Owner Information**     | **Cons   | **A       |
|                  |                           | truction | ssessment |
|                  |                           | Date**   | Date**    |
+------------------+---------------------------+----------+-----------+
| 123 Any Street   | John Craig                | 1890     | March 10, |
|                  |                           |          | 2004      |
| Syracuse, NY     | 123 Any Street            |          |           |
|                  |                           |          |           |
|                  | Syracuse, NY 13205 Ph.    |          |           |
|                  | 315-492-0556              |          |           |
+------------------+---------------------------+----------+-----------+

An initial walk-through was conducted in the dwelling to determine the
presence of suspect materials, which were accessible or exposed. The
information contained in this report has been collected in accordance
with current regulations.

**PURPOSE**

This lead based paint hazard / inspection investigation was based upon
chapter 5 and 7 of the United States Department of Housing and Community
Development (HUD) Guidelines. Reference levels are as listed below:

### DUST WIPE SAMPLES

Floors 40 µg/ft^2^

Window Sills 250 µg/ft^2^

> **XRF ASSAY PAINT**
>
> 1.0 mg/cm^2^ 0.5% Lead by weight

# WATER SAMPLES

15 Parts per Billion (ppb)

**SOIL SAMPLES**

Paving or removal criteria 5,000 ppm

Building perimeter/yard 1,200 ppm

Play/high contact areas 400 ppm

**SCOPE OF SERVICES**

A review of all available documentation concerning lead investigations
and abatements conducted in the building was completed. A visual
inspection for deteriorated paint was conducted. XRF assays and samples
of settled dust were collected in accordance with current regulations to
determine where lead paint exists and if any lead hazards were present
in the home. No soil samples were collected at this time due to snow
coverage.

**METHODOLOGY**

Upon completion of the visual inspection, XRF assays and samples of
settled dust were collected in selected locations and in a manner
consistent with chapter 5 of the HUD Guidelines.

**NARRATIVE**

On March 10, 2004 The City of Syracuse Lead Program performed a lead
based paint risk assessment / inspection at 123 Any Street in Syracuse,
New York. Settled dust and XRF samples were taken in an effort to locate
the possible sources of lead within and around the dwelling. No soil
samples were taken at this time due to snow coverage.

The City of Syracuse Lead Program followed ASTM Standard Practice E1728,
"Standard Practice for Field Collection of Settled Dust Samples Using
Wipe Sampling Methods for Lead Determination by Atomic Spectrometry
Techniques" for collection of dust wipe samples. Samples of settled dust
were collected from within the units from floors and window sills that
appeared to be the dirtiest and most accessible to children. In addition
to these samples a field blank was sent to the laboratory for quality
assurance and quality control purposes.

Within the dwelling the average of floor samples is 92.0µg/^ft2^ and the
average of window sill samples is 369.0µg/^ft2^. This indicates that a
lead dust hazard does exist at this time. It is our recommendation that
all floors and all window sills be cleaned using the HUD three step
cleaning method as described in Chapter 14-11 of the HUD Guidelines.

The City of Syracuse Lead Program tested 115 component surfaces from
this location using a Niton XL000 XRF serial number U000NR0000. The XRF
was calibrated following the manufacturer's recommended protocol before
and after the testing. Tested surfaces were selected in accordance with
Chapter 7 of the HUD Guidelines. City of Syracuse lead Program, also
considered the Onondaga County Health Department findings that are
included in this report.

A detailed list of components that were tested by the XRF is provided in
the following quick summary of analysis results with the samples
exceeding the reference limit for lead in paint indicated in boldface
type. In general, room one is defined as the first room or room
equivalent directly accessed by the main entrance and rooms are labeled
clockwise from that point. Kitchens are labeled as "kitchens" and
bathrooms are labeled as "baths". Also the "A" side of any apartment or
building is the address side of the house and the sides are then labeled
alphabetically going clockwise. If a given unit has two floors the
numbering continues with the first non-bathroom on the left unless
indicated otherwise on the floor plan.

A copy of this summary must be provided to new Lessees (tenants) and
purchasers of this property under Federal Law (24 CFR part 35 and 40 CFR
part 745) before they become obligated under a lease or sales contract.
The complete report must also be provided to new purchasers and it must
be made available to new tenants. Landlords (lessors) and sellers are
also required to distribute an educational pamphlet approved by the U.S.
Environmental Protection Agency and include standard warning language in
their leases or sales contracts to ensure that parents have the
information they need to protect their children from lead-based paint
hazards

Any lead related work that involves the removal or disturbance of the
leaded materials identified in this dwelling must be done in compliance
with lead regulations. Any surfaces not tested should be considered lead
containing.

This report can be reproduced only in full. This risk assessment report
expires March 10, 2005.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

John Doe John Doe

NY-00-000000-00 NY-00-000000-00

**QUICK SUMMARY OF LEAD TESTING RESULTS**

Dwelling: [123 Any Street, Syracuse NY]{.underline} Date: 3/10/2004

Inspector: [John Doe (EPA Cert. 00-000000-00)]{.underline}

SAMPLE LOCATION SAMPLE TYPE AREA RESULT COMPILIANCE

  --------- ----------------- ----------- ----------- ------------ -----------
  **001**   **Room 1 floor    **Wipe      **1.00      **271.9      **n**
            /entrance floor** Sample**    ft^2^**     µg/ft^2^**   

  002       Room 1 sill       Wipe Sample 0.58 ft^2^  \<34.5       y
                                                      µg/ft^2^     

  **003**   **Kitchen floor** **Wipe      **1.00      **52.7       **n**
                              Sample**    ft^2^**     µg/ft^2^**   

  004       Kitchen sill      Wipe Sample 0.13 ft^2^  \<153.8      y
                                                      µg/ft^2^     

  005       Room 4 floor      Wipe Sample 1.00 ft^2^  22.8         y
                                                      µg/ft^2^     

  **006**   **Room 4 sill**   **Wipe      **0.58      **1,224.6    **n**
                              Sample**    ft^2^**     µg/ft^2^**   

  007       Room 6 floor      Wipe Sample 1.00 ft^2^  \<20.0       y
                                                      µg/ft^2^     

  008       Room 6 sill       Wipe Sample 0.58 ft^2^  62.2         y
                                                      µg/ft^2^     

  009       Field blank       Blank                   \<20.0 µg    y
  --------- ----------------- ----------- ----------- ------------ -----------

**AVERAGE SETTLED DUST LEAD LEVELS OF FLOORS:** **92.0 µg/ft^2^**

**AVERAGE SETTLED DUST LEVELS OF WINDOW SILLS:** **369.0 µg/ft^2^**

> **[REFERENCE LIMITS]{.underline}**

######## DUST WIPE SAMPLES SOIL SAMPLES PAINT CHIP SAMPLES

> Floors 40 µg/ft^2^ Play/high contact areas 400 ppm 0.5% Lead by weight
>
> Window Sills 250 µg/ft^2^ Building perimeter/yard 1,200 ppm
>
> Paving or removal criteria 5,000 ppm **WATER SAMPLES**
>
> 15 Parts per Billion (ppb)

**Lead Hazard Control Visual Inspection Form**

Date: Name of Inspector:

License no:

Name of Property owner:

Property address: Apt. no:

  ----------------- ----------------------------- ----------- -----------
  **Room ID**       **Condition of Components in  **Visible   **Visible
                    each room**                   paint       settled
                                                  chips?**    dust?**

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              

                                                              
  ----------------- ----------------------------- ----------- -----------

Notes:

Signature

**Field Questionnaire for Lead Risk Assessments**

Location: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_/\_\_/\_\_

1\. What is the approximate age of the dwelling?

2\. Where does the child like to play or hide? Inside:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Outside: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Is the unit or are near by buildings or structures being renovated,
repainted, or demolished?

4\. Is there any deteriorated paint on exterior components?

5\. Are there any visible paint chips near the perimeter of the house,
fences, garages, or play structures?

6\. Risk assessor should note any lead-related occupation or hobby.

7\. Does the child have a favorite cup and/or eating utensil? If yes,
are they handing made or ceramic?

8\. does the child have a pet that could track in contaminated soil or
dust from the outside?

If yes, where does the pet sleep?

9\. Risk assessor should note cleaning habits within dwelling.

10\. Are there any detached structures on this site?

**[INTAKE INFORMATION]{.underline}**

**EMERGENCY CASE**?\_\_\_\_\_\_\_\_\_\_

Case #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ HUD
I.D.#\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Initial Contact
Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Street #\_\_\_\_\_\_\_\_\_\_ Street
Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Zip\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

No. of Units\_\_\_\_ Owner-Occupied: Yes\_\_\_\_\_ No\_\_\_\_\_ Property
I.D. Number.\_\_\_\_\_ - \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NSA/Neighborhood\_\_\_\_\_\_\_/\_\_\_\_\_\_ Other Property:
Yes\_\_\_\_\_ No\_\_\_\_\_ Census Tract
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

BG\_\_\_\_ Property Tax Status: (C/D) \_\_\_\_\_ Tax Trust: Yes\_\_\_\_
No\_\_\_\_ Current: Yes\_\_\_\_ No\_\_\_\_\_\_\_\_\_\_\_

Full Assessed Value \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Last Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Last
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

First Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ First
Name:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Home Phone #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work Phone
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Cell Phone
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Contact
Person:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Owner's Address if different from above:**

Street #\_\_\_\_\_\_\_\_\_ Street
Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Zip
Code\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Revised: 2/7/02 BM

**Recommendations Prioritized**

**123 Any Street**

+---+----------------+-----------------+-------------------+----------+
| * | **Component**  | **Location**    | **Method**        | **       |
| * |                |                 |                   | Reason** |
| N |                |                 |                   |          |
| O |                |                 |                   |          |
| . |                |                 |                   |          |
| * |                |                 |                   |          |
| * |                |                 |                   |          |
+---+----------------+-----------------+-------------------+----------+
| * | **Windows**    | **All windows   | **Remove and      | **       |
| * |                | meant to open** | replace with new  | Friction |
| 1 |                |                 | vinyl windows**   | s        |
| * |                |                 |                   | urface** |
| * |                |                 |                   |          |
|   |                |                 |                   | **Poor   |
|   |                |                 |                   | con      |
|   |                |                 |                   | dition** |
+---+----------------+-----------------+-------------------+----------+
| * | **Window       | **Room 7 and    | **Wet scrape and  | **Poor   |
| * | sills**        | bathroom**      | paint**           | con      |
| 2 |                |                 |                   | dition** |
| * |                |                 |                   |          |
| * |                |                 |                   | **       |
|   |                |                 |                   | Chewable |
|   |                |                 |                   | s        |
|   |                |                 |                   | urface** |
+---+----------------+-----------------+-------------------+----------+
| * | **Ceiling**    | **Side "A"      | **Wet scrape and  | **Poor   |
| * |                | porch**         | paint**           | con      |
| 3 |                |                 |                   | dition** |
| * |                |                 |                   |          |
| * |                |                 |                   |          |
+---+----------------+-----------------+-------------------+----------+
| * | **Header**     | **Side "A"      | **Wet scrape and  | **Poor   |
| * |                | porch**         | cover with        | con      |
| 4 |                |                 | aluminum coil     | dition** |
| * |                |                 | stock**           |          |
| * |                |                 |                   |          |
+---+----------------+-----------------+-------------------+----------+
| * | **Rail cap**   | **Side "A"      | **Wet scrape and  | **Poor   |
| * |                | porch**         | cover with        | con      |
| 5 |                |                 | aluminum coil     | dition** |
| * |                |                 | stock**           |          |
| * |                |                 |                   |          |
+---+----------------+-----------------+-------------------+----------+
| * | **Trim**       | **All exterior  | **Wet scrape and  | **Poor   |
| * |                | trim**          | cover with        | con      |
| 6 |                |                 | aluminum coil     | dition** |
| * |                |                 | stock**           |          |
| * |                |                 |                   |          |
+---+----------------+-----------------+-------------------+----------+

**Because this report recommends the use of encapsulates and enclosure
techniques which are not permanent solutions, it is necessary for the
owner to have a monitoring and maintenance schedule. It is recommended
that the owner inspect these areas for any damage or deterioration every
six months and upon lease renewal. If there are any signs of
deterioration, repairs should be performed by qualified personnel after
which clearance testing should be performed.**

**Anyone that intends on doing the work will attend the one-day lead
maintenance worker class for lead safe work practices.**

**Anything listed as fair condition should be monitored frequently by
homeowner.**

**The notice of Lead Hazard Evaluation will be provided by the owner to
the residents in the dwelling. The owner will explain to the residents
that the lead hazards at the property will be corrected during
renovation. After the work has been completed and clearance established,
the owner will forward a notice of Lead Hazard Reduction.**

**Any renovation work that involves the removal or disturbance of leaded
materials identified in this dwelling must be done in compliance with
lead regulations. Any surfaces not tested should be considered lead
containing. This report cannot be reproduced without the permission of
The City of Syracuse Lead Program and then only in full.**