VAppendixBAppendix

B Forms Used In Enforcement 1. Asbestos/Lead (Pb) Complaint Form (DPH 44035) Appendix
Bi 2. Inspection Report (F-47244)
Appendix B2 3. Wis. Occupational Health Lab (WOHL) Sampe Submission Form Appendix
33 4. Asbestos Project Notification (F-00041) Appendix 34 5. Notification

of Lead-Based Paint Activity (F-44012) Appendix B5 6. Sample Special Inspection Warrant Affidavit Appendix 36 7. BEOH Enforcement Routing Slip (DPH 44040) Appendix
B]Appendix
SI DEPARTMENT

OF HEALTH AND FAMILY SERVICES Division
of Public Health DPH 44035 (812000) ASBESTOS

I LEAD(PS) CDMPLAINT FDRM STATE OF WISCONSIN Bureau of OccupatiDnal Health HFS 183. \Aj Mm. Code Does complainant wish to emair anonymous? DYes ONo 

# r

Agency Referred to: 

# J DNR 

# H EPA 

# H OSHA 

# H Commerce


# H DATCP 

# H Justice 

# H Labor 

# H DA HLPHD Person Referred To:

)

I Agency: Phone #: Complaint Against individual

I Company:



# fl General Contractor Location

/ Address:



# H Sub-Contractor 

# H Landlord/Business Owner Phone Number:



# H Homeowner Individual ?Company:



# H General Contractor Location? Address:



# H Sub-Contractor,



# H Landlord/Business Owner Phone Number:



# I H Homeowner Individual

/ Company: Location! Address: Phone Number:

:— 

# H General Contractor 

# I H Sub-Contractor 

# H Landlord/Business Owner 

# H Homeowner Nature of Complaint: Notification:


# H Failure
to Notify



# H Falsifying Not±cation Certiflcaton:


# H UncertWied Workers



# H FaisifyThg Certification. Accreditation:


# H Falsifying Certificates Work Practice Violations: 

# H Following proper work practices


# H Posting signs 

# H Use of wet methods



# H Disposal preparaticn 

# H Visible emissions



# H Transport! disposal
of waste 

# H Proper containment



# H Worker protection 

# H Occupant notification



# H Other: Detailed Explanation: Laboratory Reports: Bulk Sample Results: Material Type:________ Contents:_________ 

# H PCM HTEM Content: Date: Type of Complaint: 

# H Asbestos Li Schcci 

# H Lead (Pb) Taken by: Complainant’s Name: Phone: Address: AJr Sample Results:AppendixB2DEPARTMENTOFHEALTHSERVICESDivisionofPublicHealthF-47244INSPECTIONREPORTAsbestos/Lead(Pb)CertificationProgramSTATEOFWISCONSINBureauofEnvironmentalandOccupationalHealthLeadAsbestosInspectionDate:Contractor:Supervisor’sname:Supervisoronsite:NameYesNoDHS#ExpirationDateFacility:Address:City:NameDHS#ExpirationDateAllpeopleproperlycertifiedNoticeofabatementactivityAdequatecontainment?Occupantprotectionplan?Requiredwarningsignsposted?YesNoYesNoatthesite?YesNoProjectlog?YesNogiven?YesNoPhotostaken?YesNoNumberofphotos:..YesNoSamplestaken?YesNoNumberofsamples:Comments:CompanyRepresentative:Date:Inspector:Date:ThesignaturesabovearetoverifythatacertificationinspectionhasbeenconductedatthelocationandThesignaturesdonotnecessarflymeanthereisagreementonanyallegedviolationthatmayhaveoccurred.onthedatenoted.

# Appendix B3 WISCONSIN OCCUPATIONAL HEALTH LABORATORY (WOHL) SAMPLE SUBMiSSION FORM WOHL COMP# Send Results To ATTN: Phone # FAX U 

# Email Address Project ______



# Turnaround: Date Sampled U RUSH U PRIORITY U NORMAL must be prearranged

u PLEASE GROUP SAMPLES BY MEDIA USED AND ANAL YSIS REQUESTED..



# CHAIN OF CUSTODY: Relinquished 

# UPS, Fed-Ex & Other Shippers Wisconsin 

# Occupational Health Lab 2601 Agriculture Drive 

# Madison, WI 53718 

# US Postal Service Wisconsin Occupational Health Lab P0 Box 7996 Madison, Wl 53707-7996 Received _______________



# Phone 608 224-6210 

# Sampling Questions 800 446-0403 WOHLsamplingrnaiLslIi.wisc.edu
FAX 

# 608 224-6213 

# Web Page/Order Media http://wwvv.s1h.wisc.edu/WOhI 

# Bill To



# SPECIAL INSTRUCTIONS

LAB USE ONLY WIPE 

# SAMPLES FOR AIR SAMPLES ONLY WOHL CUSTOMER SAMPLE 

# IF TOTAL 

# IF FLOW 

# ii 1 ANALYSIS 

# REQUEST SAMPLE# FIELD# MEDIA SIZEOF 

# TIME TIME 

# ji TIME RATE 

# II VOLUME AREA wrpED 

# ON 

# OFF (MINS) (LIMIN) 

# II (LITERS) EX: 2 IN x 2 IN



# Date Date SAMPLE CONDITION ________



# OK ___________



# NOT OK See Sample Receipt RecorJDEPARTMENTOFHEALTHSERVICESAppendixB4STATEOFWISCONSINDivisionofPublicHealthF-00041(5/09)PageIof4ASBESTOSPROJECTNOTIFICATIONBureauofEnvironmental&OccupationalHealthDHS159,Wis.Adm.CodeCompletionofthisformismandatoryforregulatedasbestosprojectsunbarch.DHS159,Wis.Adm.Code.ThisformmaynotbeusedtomeetthenotificationrequirementsfortheDepartmentofNaturalResources.chs.NR406,410,and447.Refertopage2andtheinstructionsforhelpcompletingandsubmittingnot[fication.ShadedareasareforDepartmentuseonly.CompanyprojectNo.SubmittedOHSNo.PROPERTYINFORMATIONPrcpertytype(checkroostaccurateresponse)HCommercial/Industrial/BusinessHPuDlic(church,library,etc.)HK-12SchoolHGovernmentEUniversityHResloential/No.UnitsHOwner-occupiedHRental]HOther:Facility/buildingname,ifaopiicaolePropertycontactpersonTelephoneNo..)NameofownerTelephoneNo..IC)StreetorfirecodeaddressCityZipLocationofprojectonpremisesASBESTOSPROJECTTYPECheckal.thatapp;yHRemovalHEnclosureHEncapsulationHRepairHOther(describe):Structurewillbe:HOccupiedHVacant(Ifoccupied,completeandpostanAsbestosOccupantProtectionPlan,FormP44016)NOTICETYPEHOriginalUCancellationHRevision,No.Revising:HScheduleHType/amountofACMHOtherHPlannedrenovationprojectStartdate(mm/dd/yy):Enddate:HSub-projectNo:PROJECTSCHEDULEStartdateincludesprojectset-upAbatementdates(rnm/dd/yy)Startdate:Enddate:Workhrs:Ha.m.Hp.m.Workdays(Checkallthatapply)HMon.Tues.HWed.HThurs.HFri.HSatHSun.toHa.m.Hp.m.PRE-PROJECTASBESTOSINSPECTIONInspectiondate(s)(mm/dd/yy)InspectornameInspectorDHScertificationNo.ABATEMENTCONTRACTORINFORMATIONCompanynameDHSCertificationNo.&ExpirationOateAddressContactpersonnameOfficeTelephoneNo..(CityStateZipCellularTelephoneNo..TYPEANDAMOUNTOFASBESTOSSeepage2forguidanceLocation:HInteriorHExteriorTotalAmountofAsbestosHFriable-Submitnotificationfor:H<260linearfeetH<60squarefeetH<35cubicfeetIHAnyamountofasbestosinresidentialbuildingswithfewerthan5units‘LinearFeeType:HPipes/ductsHSurfacingUDtherfriableACM:________________________________________HNon-Friable-Submitnotificaticnforasbestosprojectsinvclviig:Ulooring:HAnyamount,intactmanualmethods,or,U<160squarefeet.mechancachipping.SquareFeeHRoofng:HAnyamount,intactmanualmethods,or,H<5.58csquarefeet,Dower-sawingHSiding:Anyamount,intactmethodsonlyElOthernon-friaDleACM:CuoicFeeFEESSeePage2forpaymentmethods,SeeInstructionsPage2formoreonfeesHNofeerequiredFeeReceivedHOriginalnotice,2ormoreworkingdaysHSub-projectHRevision,lessthan2workingdaysH$50HOriginalnotide,lessthan2workingdaysHPlannedrenovationprojectnoticeH$100PROJECTNOTIFICATIONAFFIDAVIT--lamanauthorizedrepresentativeoftheabatementcompanynamedabove.Icertifythattheinformationprovidedonthisformiscorrecttothebestofmyknew]edgeandthatthisprojectcomplieswithCh.OHS‘159,Wis.Adm.Code.SIGNATURE—AuthorizedRepresentativeDHScertificationnumberDateSigned’F-00041 (5109) Page

2 of 4 NOTIFICATION GUIDANCE— Follow these instructions

to determine

if asbestos project notification

to DHS is required: 1. Choose the table below that matches the property type. 2. In that table, choose the row that describes the type of activity and amount of ACM involved

in the activity. 3. In that row, choose the column that describes the type of material (friable or non-friable). 4. The cell at the intersection

of the chosen row and column indicates whether
or not notice
is required

to the department. Abatement Activity

Friable Asbestos Non-friable Asbestos Removal
of more than

1 bag t of ACM and up to any amount of Notify DHS
Notify DHS removal Enclosure, encapsulation

or repair of more than

3 square

ft or more Notify OHS

No OHS notice required than

3 linearftof ACM

I Table
2: All other structures, including residential with

5 or more dwelling units Abatement Activity

Friable Asbestos Non-friable Asbestos Removal
of more than

I bag t of ACM but less than 160 square
ft Notify OHS
Notify OHS less than 260 linear ft, or less than 35 cubic ft Removal
of 160 square

ft ormore, 260 Iinearft or more, or 35 cubic
No DHS notice required t
Notify OHS ft or more of ACM Enclosure,encapsulation

or repair of more than

3 square

ft or more Notify DHS

No DHS notice required_- than

3 linear
ft of ACM *Bag) means

a disposal bag or glove bag no larger than 60” x 60”, properly filled and sealed.-- Notice
to Department

of Natural Resources may be required. Notice
is required
to DNR for removal of any amount of friable or non-friable ACM on DNR-regulated demolition projects and for friable asbestos
or RACM
in amounts more than 160 square feet, 260 linearfeet,

or 35 cubic feet for renovation projects

in residential buildings with
5 or more dwelling units and in all otherfacilities. Contact the DNR at 608- 266-2060 for more information
on DNR notification requirements. SUBM ITTING NOTIFICATION— Also see instructions
for further information
on notification requirements. Notification delivery methods allowed based on timing of submittal Original- 2 or more Original- less than
2 Revision Planned Renovation Sub-proiect

-2 or Sub-proiect- wOrking days t notice working days t notice
Proiect
more working days t than
2 working days notice notice -Fax
-Fax
-Fax
-Fax
-Fax
-Fax- Email attachment- Email attachment- Email attachment- Email attachment- Email attachment- Email attachment- Delivery service- Delivery service- Personal delivery- Delivery service- Delivery service- Delivery service- Personal delivery- Personal delivery- Personal delivery- Personal delivery- Personal delivery- Postal service

I- Postal service- Postal service • Working day’ means any day except Saturday
or Sunday. For notification purposes

a working day ends at 4 p.m. Cancellations: Submit asbestos project cancellation before the start date on the original or most recently revised notice for the project by one of the following means: fax, email attachment,

or persona] delivery as provided under Delivery Methods. Delivery methods: Use one of the following methods for delivery, as allowed, based on the information provided above:- Fax: submit notification form with credit card payment form to 608-266-9711- Email: submit notification form with credit card payment form to dhsAsbestosLeathãwi.gov- Personal delivery: submit notification form and payment

to street address- Delivery service with guaranteed delivery schedule: send notification forni and payment

to street address- U.S. postal service (must be postmarked

4 working days or more before project start): mail notification form and payment

to mailing address Mailing Address-
Street Address Department

of Health Services Department

of Health Services • Asbestos and LeadSection, Room 137 Asbestos and Lead Section PD Box 2659

1 West Wilson Street, Room 137 Madison WI 53701-2659

Madison WI 53703 Call (608) 261-6876 with questions. PAYMENT METHODS— Payment

is required
at the time notice
is submitted. See InstrUctions Page
2 for information
on determining fees.- For notification submitted
by fax or email, fee is payable only by credit card (Visa or MasterCard only) using the credit card payment form. For notification submitted
by personal delivery, delivery service) or U.S. postal service, fee is payable by credit card, check, or money order. Cash is not accepted. )EPARTMENT

OF HEALTH SERVICES

STATE OF WISCONSIN)Ivision
o Public Health

Bureau of Environmental

& Occupational Health F-00041 (5/09) Instructions

DHS. 159, Wis. Adm. Code Page

3 of 4 Instructions
for Completing Asbestos Project Notifications Each section on the notification form must be completed. The form must be signed and dated by an authorized representative

of the asbestos company conducting the project, or electronically signed and dated by the authorized representative. Company project number— Assign

a unique project number. This project number must be included on any revised or cancelled notice. PROPERTY INFORMATION— Complete the information requested about the property where the project wifl be conducted. Provide information needed
to locate the actual asbestos project worksite on the property. Enter for Property Contact Person the owner, owner representative!

or property manager

to be contacted regarding the project. Property Type. Check the box that most accurately describes the use of the portion of the property where the asbestos activity will be conducted. Commercial/Industrial/Business.
Property used for money-making purposes such as retai. firms and corporate business offices, private heaithcare facilities, wholesale and warehousing, manufacturing and production. Public. Properly not otheise describec that is routinely used by the public, such as a church, library, private college, YMCA. or other club, non-profit healthcare, community center, or community arts theater or facility. K-12 School. Public or private academic school for children

in grades kindergarten through 12. Government/University. Building owned, managed
or leased by a local, state or federal governing body or organization,

or, a 2-year or 4-year public college or university. Residential. Single-family

or multi-family dwellinc, apartment, condominium,
loft: dormitory
or other facility where any person resides. Include the total number of owelling units in the structure and check whether the property

is owner-occupied

or rental. Other. Any othertye
of building or structure, including facilities such as: water towers, bridges, tunnels, parking structures. ASBESTOS PROJECT TYPE— Check all boxes that apply. Removal. Activity that takes out any or all ACM or suspect ACM in or on a structure
or takes out any or all structural components that contain or are covered with ACM or suspect ACM. Enclosure. Activity that creates an airtight, impermeable, permanent barrier over or around ACM. Encapsulation. Activity that treats ACM 4th
a product specfically designed

to surround
or embed asbestos fibers in an adhesive matrix. Repair. ActMty that returns damaged ACt) to an undamaged condition
or to an intact stale. Other. Activity not covered by standard abatement activities, such as chemical
or mechanical conversion. Occupancy: Check the box that best describes the occupancy status of the structure during the asbestos activity. Check ‘Occupied’

if any part of the attached structure will be occupied by persons orfurnishings. Check ‘Vacant’

if the structure will be empty of both occupants and furnishings
fo the duration. Note:
If the structure will remain occupied

or furnished during the asbestos activity, an Occupant Protection Plan, Form F-44D1

6 must be completed and posted
in plain view outside each reguiated area. NOTICE TYPE— Check appropriate boxfor origiriai, cancellaticn, revision, planned renovation project or sub-project notice. Original. Provides first written notice for a project. Cancellation. Cancels

a project already notified. Once cancelled,

a notice can not be reactivated.

If a project
is re-scheduled after being cancelled,

a new notice with fee is required. Revision Changes information
on a previously submitted project notic& Enter the number of the revision

in the space provided, (the first revision

is Revision No. 1). Check box or boxes to indicate what information

is being revised, the schedule, type or ahnount
of ACM, or other (please describe). Circle al changed infcrmatior.
on the notice form.- For
a later start date, submit before the start date pn the originai notice.- For an earlier start date, submit
at Jeast2 workng days before the revised start date. Revised notice submitted less than
2 working days before the new start date shall include

a $50 tee.- For an earlier end date, submit as soon as known.- For a. later end date, submit before the project end date on the previous notice.- A notice may not be revised after the project end date provided on the previous notice.

A new original notice with fee must be submitted. Planned Renovation Project. Provides notice for a planned renovation project expected

to include

a series of asbestos abatement activities conducted within

a gven time period not to exceed one year.- Notice shall be subrnittec

at least

2 working days before the start of the planned renovation project.- Provide the renovation project start and end dates, nct to exceed 12 months

in length. Sub-project number. Sub-projects under planned mencvation proecl notices must be separately no:ifed
to the department and must reference the company project numberforthe planned renovation project notice. For each sub-project notice under

a Planned Renovation Project notice, assign

a sub-project number that sequentially numbers the sub-projects
for the renovation project (with the first sub-project numbered

1). Submit separate notice for each new sub-project when the asbestos activity meets the requirements
for notification

to DHS under Ch. DHS 159.20 (1), Wis. Adm. Code, and as provided on the tables on Page

2 of the notice form. Note: Keep

a copy of any rotice you submit. Use the copy for any future revisions. Make sure copies are clear and legible.F-00041 (5109) Instructions Page
4 of 4 PROJECT SCHEDULE— Projectdates include the date set up begins and ends when the regu!ated areas are rnoved
or dismantled. Abatement dates. Enter the start date and the end date for the project or sub-project, including set up dates. Work days. Check the boxes for the days of the week workers will be on the job. Work hours. Enter the standard daily work hours for the project— daily start and stop limes. Note: A revised notice must be submitted whenever

a start or end date or standard work schedule changes. Accurate information

is necessary

to allow the department

to conduct onsite inspections

as work is being conducted.

If no one is present on site when

a department representative arrives, the contractor may be found
in non-compliance with Ch. DHS 159, Wis. Adm. Code. PRE-PROJECT ASBESTOS INSPECTION- If the structure was inspected prior to the asbestos abatement project (required for all demolitions, renovations, planned renovation projects and schools), complete The information requested, including the date the inspection was completed, the inspector’s name and department certification number.- ABATEMENT CONTRACTOR INFORMATION- Enter all information requested

in this section. The contact person should be an authorized representative

of the company who is knowledgeable about the project. This person should be readily available
to the department

by telephone throughout the project. Note: The company certification number and expiration date are located on the company certificate mailed
to the asbestos company after certification approval was granted. This number must be provided with all notices submitted

to the department. TYPE AND AMOUNT OF ASBESTOS- Check location of abatement project, type of asbestos and amount of asbestos

to be abated. Page
2 of the notice form provides guidance

to determine when notice
is required
to DHS. You also need to detem,ine

if notice
is required
to DNR. This Asbestos Project Notification form is good only for notification

to DHS. Check with DNR at 608-266-2060

for their notification requirements and forms. Interior! Exterior. Check one or both boxes to indicate the project location or locations. Friable? Non-Friable. Check enS or both boxes to indicate the type(s) of ACM to be abated. Friable.- Check the box or boxes that describe the amount of ACM or That project

is at a residential structure with fewer than

5 units- Check the box or boxes for the types of material- pipes/ducts, surfacing,
or other friable ACM.- If ‘other’
is checked, describe the material. Non-Friable.- Check the box or boxes for the types of materials -flooring, roofing, siding, or other non-friable ACM- If ‘flooring’
or ‘roofing’

is checked, also check whether manual or mechanical methods will be used.- If ‘other’
is checked, describe the material. Amount
of Asbestos.

In columh

2 enter the total amount of ACM to be abated
in linear, square or cubic feet. Use cubic feèt.only

if unable to describe amount

in linear.or square feet. Use the guidance tables on page

2 of the form to determine

if notification

is required
tà OHS. Notification may be required

to DNR. Contact DNR at 608-266-2060
for information
on DNR notification requirements. FEES- Determine the notification fee, if any. Check the ‘No fee required’ box if the project does not require

a fee (see ‘revised notice and ‘planned renovation project and sub-project notices’ below for cases where no fee is required). g: A ‘working day’ means any day except Saturday, Sunday,
or state or federal holidays- Notices submitted after 4:00 p.m. are considered submitted the next working day. Original notice: $50 for an original notice submitted

2 working days or more before the project start date. $100 for an original notice submitted less than
2 working days before the project start date, Revised notice:- $50 when

a revision
to an earlier tart date is submitted less than
2 working days before the new start date. No fee is required for any other revision. Planned Renovation Project and Sub-Project notices: $100 for a planned renovation project notice. $50 for a sub-project notice submitted less than
2 working days before the start date of the sub-project. No fee is required for a sub-project notice submitted

2 working days or more before the start date. Completing the fee section.- If no fee applies, check the ‘No fee required’ box.- If a fee applies, check the box that best describes the notification: original, sub-project, revision or planned renovation.- Check the appropriate fee amount

in the Fee Enclosed column.- attach the fee: credit card, check, or money order depending
on The delivery method. See the notice form Page
2 for more on payments. PROJECT NOTIFICATION AFFIDAVIT— The notification form must be signed by an authorized company representative who can vouch for the accuracy
of the information provided. REVISIONS- Whenever information for a project changes, submit

a revised notice to the department
on a copy of the original notice. To Domplete the revised notice, be sure the original project number

is clearly identified;

in the ‘Notice Type’ section of the form check ‘Revision’ and enter the number of therevision

in sequential order; circle or otherwise highlight
all revised information. Revised notices may be submitted
by the following means: fax, email attachment,

or personal delivery as provided on page

2 of the notification form. Any fee required• & a revision shall be submitted With the revision.DEPARTMENTOP HEALTH SERVICES AppendIx
25

STATE DPWISCONSIN Division
of Public Health

Bureau of Occuoational ealth F-44012 (O910Q

HFS 161 Wis. Adm Code NOTIFICATION

OF LEAD BASED PAINT ACTIVITY Read separate instructions, DPH 440121, before completing this form. Lead Company Project Number A- PROPERTY OR RESIDENCE INFORMATION (Check most accurate response) Type: C Commercial Business

C Day Care/Preschool

C Government

C HUD Residential

C K-12 School fl ead-Safe Facility-Certificate Number____________________ ELeao-Safe Residential-Certificate Number C Manufacturing

C Public
C Residential (Number
of units

) C Universfty School COthe_ Occupancy: Is building occupied
or frequented
by a child under the age of 6? C Yes C No If a residence,

is the building occupied only by the owner and the owner’s immediate family? C Yes C No Prcperty Name,

if applicable ______________________________________________________

Number
of Units Street or Fire Code Address City ___________________________________________________________________

ZIP Code__________________ Property Contact Person _______________________________________
Telephone Number— Name of Property Owner __________________________________________
Telephone Number— B. PROJECT TYPE Ordered Lead Abatement

C Lead Abatement

C Temporary Lead Hazard Reduction

C Renovation/Remodeling C Maintenance C. RESTRICTED PRACTICES Will any of the following restricLed activities be performed? (Check ‘Yes’
if only one cf the following apply) C Yes C No Abrasive Blasting/Sandblasting Machine Chipping/Grinding/Planing/Sanding

Paint Stripping Power Washing Removing Components

Use of Heat Gun D. TYPE OF NOTIFICATION C OriinaI Not ice C Revision Numbe New Start Date New End Date

C Canceflation

C Emergency E. PROJECT DATES) HOURS Start Date (mm/dd/yy)

End Date (mm/dd/yy) Shift(s):
1st C 2nd C 3rd Weekend
C Yes C No F. CERTIFIED LEAD ABATEMENT COMPANY INFORMATION (Company performing lead-base paint activities) Company Name

WI Lead Certification No. Street Address City

State

ZIP Code Company Contact Person
Telephone Number G. LEAD IDENTIFICATION C Lead Assumed Present

C Size Tested
C Unknown Lead Investigator Name

WI Lead Certifcation Nc.

Date Lead Identified H. PROJECT INFORMATION

C Interior work
C Exterior work Number Number of Estimated exterior Estimated of rooms windows square footage___________________ Project Cost

S I am a certified lead supervisor and authorized representative
for the certified lead company above.

I certify that to the best of my knowledgethis project complies with HFS 163, Wisconsin Administrative Code, and all applicable state, federal, and local regulations. SIGNATURE— Lead Supervisor/AuthorIzed Representative Signee’s WI Lead Certificaticn

ID No. Date SignedF-44012 (09/09) Page

2 

# iE1F Local ordinances may apply In this lead project. For information about

a local ordinance, contact the local health department. : When

a lead permt
is required by a City o 4 Milwaukee ordinance, submit this form (and fee when required)

to the City of Milwaukee Health Departrnent(MHD)

and show,

a valid Wisconsin lead supervisor certification card. MHD may suspend
or deny

a permit fcrfailure to comp!y wtn any municipal requtement relating
to cad hazard reduction. Call MHZ at 414-285-0387
for detailed nformation. Local Lead Permit Number___________________________ The foliowing format
is being provided
as an example
of informatior that must be included

in a Mandatory Written Abatement Report. The use of this format
is optional and
a company may choose use
a different format, but
a written report must be completed. Mandatory Written Abatement Report Complete number

1 prior to commencing abatement activity. Complete numbers

2 and

3 after abatement project

is completed. 1. List name(s) and WI Lead Certification number of each supervisor assigned

to project: 2. Abatement dates

if different from dates on the front of side of the form. Start Date’ Completion Date’ 3. Attach or provide here
a detailed description

of the abatement, including locations
of rooms and components where abatement occurred, abatement methods used for each component and reasons for selecting them, and any suggested monitoring

of encapsulants

or enclosures.

If a copy of the abatement contract
or orders

is attached, describe any changes from the contract
or order and give any additional details needed
to provide

a clear picture of the actual abatement. Attach

a copy of the Clearance Reportfrcm the lead company that conducted the ciearance for this project and Division of Public Health Cccupant Protection Plan that was prepared before the project started. Give

a copy of tte tl abatemeot report, including the Notification of Lead Based Paint Activity (this form page 1), Occupant Protection Plan, and Clearance Report,
to the person who contracted for the abatement services. Retain

a copy for the company records.DEPARTMENT

OF HEALTH SERVICES

STATE OF WISCONSIN Division
of Public Health

Bureau of Dccupational Health F-440121 (09)09)

HFS

163. Wis. Adm. Code Instructions for Completing the Notification

of Lead Based Paint Activity Provide the Lead Company’s Prciect Number. Every tern in sections

A through

H must be completed. (Refer to Chapter HFS 16114(2), Wisconsin Administrative Code for the regulations concerning notification.) Mail the completed form to the Department

of Health Services Asbestos and Lead Section, Room 137, RD. Box 2659, Madison, W 53731-2559, orfax to (608) 255-9711. A. PROPERTY INFORMATION Type. Check one box that most accurately describes the use of the portion of the building where this lead based paint activity will be conducted. Commercial Business. Commercial business, such as a restaurant, store, shopping mall, health club, or private business not involved in manufacturing. Day Care! Preschool. Premises used forthe supervision

of children of preschool age. Government. Building owned managed
or used by a locai, state or federal governing body or organization. HUD Residential. Pre-1973 housing that is federally owned or receives federal assistance. K-12 School. Pubic or private academic schoo: for children

in any grade: kindergarten through 12. Lead-Safe Property. Premises with
a valid certIficate
of ead-safe status in effect, that is not
a dwehing
or child-occupied facility. Lead-Sate Residence. Dwelling
or dwelling unit with
a valid certificate

of lead-safe status
in effect Manufacturing. Building involved

in manufacturing. Public. Building not otherwise described that is routinely used by the public, such as a church, libraiy, YMCA. or other club. Residential. Dwelling, apartment,

or other area where any person resides, that does not have

a valid certificate
of lead-safe status
in effect. University. University
or college. (Check Commercial businesC box for any university-owned commercial business tnat is not directly related
to the education
of university students.) Other. Any other building. Explain how the building

is used. Occupancy. Check the correct response

to both questions. Always answer ‘yes” tc question number

i i the building
or any portion of the building

is used as a day care, pre-school and or provides services

to children on-site. Complete

aB information requested about the property where the project will be conducted. For “Property Contact Person, enter the name and telephone number of the person to be contacted about the project B. PROJECT TYPE. Check one box as fclows: Ordere,d Lead Abatement

A local, state, or federal health agency has ordered the lead abatement

to be done. Abatement includes any measure intended
to permanently reduce

a lead hazard under normal conditions, such as removal, enclosure,

or encapsulation

of aleadbased paint component. Affach orders that describe what work is to be done or have orders at the work site for review by state or local government staff. Lead Abatement Lead abatement project other than ordered lead abatement work. Abatement includes any measure intended
to permanently reduce

a lead hazard under normal conditions, such as removal, enclosure,

or encapsulation

of a.lead-based paint component. Temporary Lead Hazard Reduction.

A non-abatement lead based paint hazard reduction activity, such as cleaning
or paint stabilization. Renovation/Remodeling. Activity thai disturbs
or emoves lead-based paint, where the intent
is not to reduce or eliminate

a lead based paint hazard. Maintenance. Activity that disturbs lead based paint in the process of keeping buildings

in good repair, and is not intended
or designed to reduce lead based paint hazards. C. RESTRICTED PRACTICES. Check the “Yes” box if any of the restricted practices listed will be performed during the lead-based paint activities. B. TYPE OF NOTIFICATION. Check one box as folows: Original notice. First written notice for a project that is not an emergency. Note: The lead abatement supersor rn’jst submit the Notification

of Lead Based Paint Activity (DPH 4402) for receipt by the Department of Health and Family Service

a minimum

of two working days before the project starts. Working days are counted by induding the day the notice

is received and excluding the day the project starts. For example,

a project for a notice received on Friday,

2 may start on Tuesday, and
a project fo a notice received on Monday, may start or Wednesday.F-440121 (09109) Page

2 Revised notice. Changes

to a previously written notice. Enter the total number of revised written notices for this project, not counting the original written notice.

A new notice, not a revision, must be submitted when

a project change

is submitted after the project end date on the previous notice. Note:
A revised notice
is required when the project star or end cate changes. To make changes and tracking easier, keep

a copy of any notice you submit Then, to revise

a notice, make

a photocopy

of the last notice you submitted, put a line through the information being changed, enter the new information, keep

a photocopy and send the revised notice to the Asbestos

& Lead Section. The Asbestos

& Lead Section must receive your revised notice: •

a minimum
of 2 working days before the oroject begins when the start changes

to an earlier date. •

a minimum oft working day before the orlginal start date when the start date changes

to a later date. • no aler than me original end, date when the project will not end on the date in the notice. Cancellation. The project has been canceled. Note: Once canceled,

a notice cannot be reactivated.

If the project continues
or restarts after

a notice
is canceled, submit

a new nouce. Emergency notice. Project

is being started on an emergency basis with less than
2 working days notice. Keep records that verity an emergency existed. Note: [‘lotice
is required before the project starts.

It emergency notice
is not sent by fax emergency notification may be made by telephone followed by written notice to the Asbestos

& Lead Section within 48 hours. E. PROJECT DATES/HOURS. Dates Enterthe dates you expecttc start and end the actual project. Note:
A revised notice must be submitted whenever

a start or end date changes. Accurate information

is necessary

to allow anonsite review of the project to be conducted.

If no one is present
at the facility when an on-site review

is conducted, the contractor may be found out of compliance with Chapter HFS 163, Wis. Administrative Code. Shift(s)- check all work shifts that appjy orthis lead abatement/hazard reduction project. First shift, approximately

7 art —3p.m. Second shi,approximately

3 p.m. —11 p.m. Third shift, approximately

it p. m. —7a.m. Check the appropriate box regarding weekend work on the lead abatement’hazard reduction project. F. CERTIFIED LEAD ABATEMENT COMPANY. Enter the certification number, name, and address
of the certified lead abatement company. Any company, partnership, corporation, sole proprietorship, association, governmental agency or other entitythat offers, supervises,

or performs lead-based paint activities, including abatement,

is required
to be certified as a lead company. An individual may not conduct abatement except under

a certified lead company. Enterthe name and telephone number
of the person to be called with questions about the project. Note: rhe lead company certification number

is located on the certificate mailed
to the lead cOmpany after certification approval was granted.

if you cannot locate your certification number, please contact the Asbestos

& Lead Section at (608) 261-6876. 

# a LEAD IDENTIFICATION. Check one box as follows. Lead Assumed Present. You assume lead is present, but testing or sampling was not done. Site Tested.

A lead inspection

or risk assessment was conducted. Unknown.

It is not known

if testing or sampling was conducted. If Site Tested box is checked, enter the consultant’s name, the consultant’s
WI lead certification identification number, which will start with either “LII”, “LHI’ or “LRA”, and the date the inCpection

or risk assessment was conducted. Note: The lead inspector
or risk assessor must give

a written report to the person paying for the lead management services after the investigation

is completed.

In addition
to the results of the lead inspection

or risk assessment, this report must include the consultant’s name, W lead certificatior, identification number, and the date the inspection

br sk assessment was completed.

A copy of this report should be provided

to the contractor

to ensure abatement

or interim controls are conducted with accurate information. H. PROJECT INFORMATION. Check the interior and/or exterior box as appropriate. if appropriate, enter the number
of rooms that will be undergoing lead based paint activities. If appropriate, enter the number
of windows that will be undergoing lead based paint activities. For exterior projects, the estimated square feet of the lead based paint activity. The estimated cost of the lead based oaint activity, The notification must be reviewed for accuracy and signed bythe certified lead supervisor who is authorized

to represent the lead company. Erter the certifed supeMscr’s
WI lead certification identification number and the date the notice

s actually signed. Do not enter

a date differentfrom
the actual date of signature. Side
2 of the notification formis optional.

It maybe used to record information which
is required
as part of the abatement report.APPENDIX
Be Sample Special Inspection Warrant Affidavit AFFIDAVIT STATE OF WISCONSIN

• CountyInthecourtofthe____________

of______________ ________________________
being duly sworn, says that on the_______ day of_____________

19, in said county,

in and upon certain premises

in the_____________

of_______________________

and more pahicularly described
as follows: there now exists

a necessity

to determine

if said premises comply with section

of the Wisconsin statutes. The facts tending
to establish the grounds for issuing

a special warrant are as follows: ____________________________________________________ Wherefore, the said_________________________

prays that
a special inspection warrant be issued to search such premises for said purpose. Subscribed and sworn to befcre me this_______ day of_________________ 20______________ Judge of the CourtAppendix B7 DEPARTMENT
DF HEALTH SERVICES

STATE OF WISCONSIN Division
of Public Health

Bureau of Environmental

& Occupational Health DPH 44040 (8109)

OHS 163, Wis, Mm. Code BEOH Enforcement Routing Slip Case name:

DHFS #:
Case #: Preparer:

Date prepared: Preparer’s comments: Reviewed by; Initials/Date- Draft nitiais/Date— Comments; (asppropriate): Review

Final Review.

1 2j Env. Health Specialist; Env. Health Specialist Regulatory Specialist Other A & L Unit Supervisor: BEOH Direzcr: Legal Counsel
(Return
to Fred Johnson)

rev. 08103109DEPARTMENT

OF HEALTH SERVICES Appendix B5

STATE OP WISCONSIN Division
of PubNc Health F-44012 (D9)09 NOTIFICATION

OF LEAD BASED PAINT ACTIVITY Bureau of Occuoationai Heaith HFS 163. Wis. Adm. Code Read separate instructions, DPH 440121, before completing this form. 

# j Leac Company Project Number A. PROPERTY OR RESIDENCE INFORMATION (Check most accurate response) Type: 5 Commercia 3usiness Li Lead-Safe Facility-Certificate S Manufacturing

5 Public Occupancy:

5 Day Care/Preschool

5 Government

5 HUD Residental

5 K-12 School Number__________________ 5Lead-Safe Residentiai-Certificate Number Li Residential (Number
of unitc

) 5 Lniversity School DOtheL Is building occupied
or frequented
by a child under the age of 6? 5 Yes LI No If a resioence,

is the Duild!ng occupied only by the owner and the owne?s immediate family? LI Yes 5 No Property Name,

if applicable

Number of Units Streel or Fire Code Address City

ZIP Code Property Contact Person
Telephone Number Name of Property Owner
Telephone Number Number of rooms Number
of windows Estimated exterior square footage Estimated Project Cost I am
a certified lead supervisor and authorized representative
for tne certified lead company above.

I certify that to the best of my knowledgethis project complies with HFS 163, Wisconsin Administrative Code, and all applicable state, federal, and local regulations. B. PROJECT TYPE LI Ordered Lead Abatement

5 Lead Abatement

LI Temporary Lead Hazard RedcJon

5 Renovation/Remodeling 5 Maintenance C. RESTRICTED PRACTICES Will any of the following restricted activities be performed? (Check ‘Yes’
if only .one of the following apply) 5 Yes C No Abrasive Basting/Sardblasting Machine Chippino/Grinding/Planing/Sanding

Paint Stripping Power Washing Removing Components

Use of Heat Gun 0. TYPE OF NOTIFICATION C Original Notice C Revision Number New Start Date New End Date

5 Cancellation

S Emergency E. PROJECT DATES

I HOURS Start Date (mm/ddlyy)

End Date (mmIddi’) Shift(s):

5 1st 5 2nd 5 3rd Weekend
C Yes 5 No F. CERTIFIED LEAD ABATEMENT COMPANY INFORMATION (Company performing lead-base paint activities) Company Name

WI Lead Certification No. Street Address City

State

ZIP Code Company Contact Person
Telephone Number G. LEAD IDENTIFICATION Lead Assumed Present



# 5 Site Tested



# 5 Unknown Lead Investigator Name

WI Lead Certfication No.

Date Lead ldentfied H. PROJECT INFORMATION



# 5 Interior work


# 5 Exterior work SIGNATURE— Lead SupervisorlAuthorizeb Representa:ive Sgnee’sWl Lead Certification

ID No. Date SignedF-44012 (09109) Page

2 Note: Local ordinances may apply to this lead project. For information about

a local ordinance, contact the local health department.



# ] When

a lead permit
is required by a City of Milwaukee ordinance, submit this form (and fee when required)
to the City of Milwaukee Health Department (MHD) and snow,

a valia Wisconsin lead supervisor certification card. MHD may suspeno
or deny

a permit forfailure to compy will, any muncipal requirement relating
to lead hazaro ‘eduction. Call MHD at 414-286-0387
for detailed information. Local Lead Permit Number___________________________ The following format
is being provided
as an example
of information that must be included

in a Mandatory Wrftten Abatement Report. The use of this format

is optional and
a company may choose use
a different format, but a written report must be completed. Mandatory Written Abatement Report Complete number

1 prior to commencing abatement activity. Complete numbers

2 and

S after abatement project

is completed. 1. Ust name(s) and WI Lead Certification number of each supervisor assigned

to project: 2. Abatement dates

if different from dates on the front of side of the form. Start Date- Completion Date 3. Attach or provide here

a detailed description

of the abatement, including iocations
of rooms and ccmponents where abatement occurred, abatement methods used for each component and reasons for selecting them, and any suggested monitoring

of encapsulants

or enclosures.

If a copy of the abatement contract
or orders

is attached, describe any changes from the contract
or order and give any additional details needed
to provide

a clear picture of the actual abatement. Attach

a copy of the Clearance Report from the lead company that conducted the ciearance for this prcject and Division of Public Health Occupant Protection Plan that was prepared before tie project started. Give

a copy of he full abatement report, inciuding the Notification of Lead Based Paint Activity (this form page 1), Occupant Protection Plan, and Clearance Report,
to the person who contracted for the abatement services. Retain

a copy for the company records.DEPARTMENT

OF HEALTH SERVICES

STATE OF WISCONSIN Division of Public Health

Bureau of Occupational Health F-440121 (09109)

HFS 163, Wis. Adm. Code instructions for Completing the Notification

of Lead Based Paint Activity Provide the Lead Company’s Project Number Every item in sections

A through

H must be completed. (Refer to Chapter HES 16114(2), Wisconsin Administrative Code for the regulations concerning notification.) Mail the completed form to the Decarment

of Heait[n Services, Asbestos and Lead Section, Room 137, P.O. Box 2659, Madison, W15370t-2659, orfaxto (606)266-9711. A. PROPERTYINFORMATION Type. Check one box that most accurately describes the use of the portion of the building where this lead based paint activity will be conducted. Commercial Business. Commercial business, such as a restaurant, store, shopping mall, health club, or private business not involved in manufacturing. Day Care! Preschool. Premises used forthe supervision

of chidren of preschool age. Government. Building owned, managed
or used by a local, state orfedera governing body or organization. HUD Residential. Pre-1978 housing that is federally owned or receives federal assistance. K-12 School. Public or private academic school for children

in. any grade: kindergarten throuoh 12. Lead-Sale Property. Premises with
a valid certificate
of lead-safe status in effect, that is not
a dwelling
or child-occupied facility. Lead-Safe Residence. Dwelling
or dwelling unit with

a valid certificate

of lead-safe status
in effect. Manufacturing. Building invoved

in manufacturing. Public. Building not othenvise descrioed that is routinely used by the pub[c, such as a church, library, YMCA, or other club. Residential. Dwelling, apartment,

or other area where any person resides, that does not have

a valid certificate
of lead-safe status
in effect. University. University
or college. (Check “Commercial business” box for any university-owned commercial business that is not directly related
to the education
of university stucents.) Other. Any other building. Explain how the building

is used. Occupancy. Check the correct response

to both questions. Always answer ‘yes” to question number

I if the building
or any portion of the building

is used ès a day care, pre-school and or provides services
to children on-site. Complete
all information requested about the property where the project will be conducted. For “Property Contact Person,” enter the name and telephone number of the person to be contacted about the project B. PROJECT TYPE. Check one box as follows: Ordernd Lead Abatement

A local, state, or federal health agency has ordered the lead abatement

to be done. Abatement includes any measure intended
to permanently reduce

a lead hazard under nOrmal conditions, such as removal, enclosure,

or encapsulation

of aleadbased paint component. Attach orders that describe what wok
is to be done or have orders at the work site for review by state or local government staff. Lead Abatement Lead abatement project other than ordered lead abatement work. Abatement includes any measure intendedto permanently reduce

a lead hazard under normal conditions, such as removal, enclosure,

or encapsulation

of a lead-based paint component. Temporary Lead Hazard Reduction.

A non-abatem&it lead based paint hazard reduction activity, such as cleaning
or paint stabilization. Renovation/Remodeling. Activity that disturbs or removes lead-based paint, where the intent
is not to reduce or eliminate

a lead based paint hazard. Maintenance. Activity that disturbs lead based paint in the process
of keeping buildings

in good epair, and is not intended
or designed to reduce lead based paint hazards. C. RESTRICTED PRACTICES. Check the “Yes” box if any of the restricted practices listed will be performed during the lead-based paint activities. D. TYPE OF NOTIFICATION. Check one box as follows: Original notice. First written notice for a project that is not an emergency. Note: The ead abatement supervisor rrnist submit the Notificator

of Lead Based Paint Activity (DPH 44012) for receipt by the Department of Health and Family Service

a minimum

of two working days before the project starts. Working days are counted by including the day the notice
is received and excluding the day the project starts. For example,

a project for a notice received on Friday,

2 may start on Tuesday, and
a project for a notice received or. Monday, may start on Wednesday.F-440121 (09109) Page

2 Revised notice. Changes
to a previously written notice. Enter the total number
of revised written notices for this project, not counting the original written notice.
A new notice, not a revision, must be submitted when

a prolect change

is submitted after the project end date on the prevbus r,otce, Note:
A revised notice
is requireo wnen the proect start or end date changes. To make changes and tracking easier, keep

a copy of any nolice you submit. Then, to revise

a notice, make

a photocopy
of the last notice you submitted, put a line through the information being changed, enter the new information, keep

a photocopy and send the revised notice to the Asbestos

& Lead Section. The Asbestos

& Lead Section must receive your revised notice: •

a minimum
of 2 working days before the project begins when the start changes
to an earlier date. •
a minimum
of

1 workinc day before the criginai start date when the start date changes

to a later date. • no later than the original end, date when the project wilt not end on the date in the notice. Cancellation. The project has been canceled. Note: Once canceled,

a notice cannot be reactivated,

If the project continues

or restarts after
a notice

is canceled, submit

a new notice. Emergency notice. Project

is being started on an ernerger,cy basis with less than
2 working days notice. Keep records that verify an emergency existed. Note: Mctice

is required before the project starts.

If emergency notice
is not sent by fax emergency notification may be made by telephone followed by written notice to the Asbestos

& Lead Section within 48 hours. E. PROJECT DATES/HOURS. Dates- Enter the dates you expect
to start and end the actual project. Note:
A revised notice must be submitted whenever

a start or end date changes- Accurate information

is necessary

to allow anonsite review of the project to be conducted.

If rio one is present
at the facility when an on-site review isconducted,
the contractor may be found out of compliance with Chapter HFS 163, Wis. Administrative Code. Shift(s)- check all work shifts that app)y forthis lead abatement/hazard reduction project First shift, apnroximately 7a.m.‘— 3p.m. Second shift, approximately

3 p.m. —II p.m. Third shift, approximately

II p. m. —7a.m. Check the appropriate box regarding weekend work on the lead abatement/hazard reduction project. F. CERTIFIED LEAD ABATEMENT COMPANY. Enter the certification number, name, and address pf the certified lead abatement company. Any company, oartnership, corpcraton, sole proprietorship, association, govemmental agency or cther entitythat offers. supervises,

or performs lead-based paint activities, including abatement,

is required
to be certEfied as a lead company. An individuai may not conduct abatemart except under

a certified lead company. Enter the name and telephone number othe person
to be called with questions about the project. Note: The lead company certification number

is located on the certificate mailed to the lead company after certification approval was granted.

If you cannot locate your certification number, please contact the Asbestos

& Lead Section
at (608) 261-6876. G. LEAD IDENTIFICATION. Check one box as follows. Lead Assumed Present You assume lead is present, but testng or sampling was not done. Site Tested.

A lead inspection
or risk assessment was conducted. Unknown,

It is not known

if testing
or sampling was conducted.- If Site Tested box is checked, enter the consuJtant’s name, the consultant’s
WI lead certification identification number, which will start with either “LII”, “LHI’ or ‘LRA”, and the date the inpection

or risk assessment was conducted. Note: The fead inspector
or risk assessor must give

a written report to the person paying for the ead management services after the investigation

is completed.

In addition
to the results of the lead inspection

or risk assessment, this report must include the consultant’s name, WI lead certification identification number, and the date the inspection

or risk assessment was completed.

A copy of this report should be provided

to the contractor

to ensui’e abatement

or interim controls are conducted with accurate information. H. PROJECT INFORMATION. Check the interior and/or exterior box as appropriate. If appropriate, enter the number of rooms that will be undergoing lead based paint activities. If appropriate, enter the number of windows that will be undergoing lead based paint activities. For exterior projects, the estimated square feet of the lead based paint activity. The estimated cost of tie lead based paint activity. The notification must be reviewed for accuracy and signed bythe certified lead supervisor who is authorized

to represent the lead company. Enter the certified supervisor’s
WI lead certification identification number and the date the notice
is actually signed. Do not enter

a date differenttrom
the actual date of signature. Side

2 of the notification form is optional.

It may be used to record information which

is required as part of the abatement report.APPENDIX
66 Sample Special Inspection Warrant Affidavit AF F

I DAV T STATE OF WISCONSIN____________________ CountyInthecourtofthe___________

of_____________ ________________________
being duly sworn, says that on the_______ day of_____________

19, in said county,

in and upon certain premises

in the_____________

of_______________________

and more particularly described
as follows: there now exists

a necessity
to determine

if said premises comply with section

of the Wisconsin statutes. The facts tending
to establish the grounds for issuing

a special warrant are as follows: ____________________________________________________ Wherefore, the said_________________________

prays that
a special inspection warrant be issued to search such premises for said purpose. Subscribed and sworn to before me this_______ day of_________________ 20_____________ Judge of the CourtAppendix B7 DEPARTMENT
OF HEALTH SERVICES Division
of Public Health DPH 44040 (8109)

BECH Enforcement Routing Slip STATE OF WISCONSIN Bureau of Environmental

& Occupational Health DHS 163, Wis. Mm. Code Reviewed h: Initials/Date- Draft Initials/Date— Comments: (as appropriate): Review

Final Review 1

2 Env. Health Specialist:

I Env. Health Specialist: Regulatory Specialist Other A & L Unit S’jpewisor: BEOH Director Legal Counsel
(Return
to Fred Johnson)

rev. 08103/09