3. Wis. Occupat

(

) 

p

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]
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:

AJr Sample Results:
Supervisor on site:

Name

Yes No

DHS # Expiration D ate

City:

Name DHS # Expiration Date

All people properly certified

Notice of abatement activity

Adequate containment?

Required warning signs posted? Yes No Occupant protection plan? Yes No

at the site? Yes No Project log? Yes No

given? Yes No Photos taken? Yes No Number of photos:.

. Yes No Samples taken? Yes No Number of samples:

Comments:

Company Representative: Date:

Inspector: Date:The signatures above are to verify that a certification inspection has been conducted at the location andThe signatures do not necessarfly mean there is agreement on any alleged violation that may have occurred.

on the date noted.
Appendix B3 WISCONSIN OCCUPATIONAL HEALTH LABORATORY (WOHL) SAMPLE 

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.e

FAX 608 224-6213 Web Page/Order Media

http://wwvv.s1h.wisc.edu/WOhI

Bill To

SPECIAL INSTRUCTI

LAB USE ONLY WIPE SAMPLES FOR AIR SAMPLES ONLY

WOHL CUSTOMER SAMPLE IF TOTAL IF FLOW ii 1 A

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 
Facility/building name, if aopiicaole

Property contact person Telephone No. . )

Name of owner Telephone No.

. IC )

Street or fire code address City ZipLocation of project on premises

ASBESTOS PROJECT TYPE Check al. that app;yH Removal H Enclosure H Encapsulation H Repair H Other (describe):Structure will be: H Occupied H Vacant (If occupied, complete and post an Asbestos Occupant Protection Plan, Form P44016)

NOTICE TYPE

H Original U Cancellation H Revision, No. Revising: H Schedule H Type/amount of ACM H Other

H Planned renovation project Start date(mm/dd/yy): End date: H Sub-project No:

PROJECT SCHEDULE Startdate includes project set-up

Abatement dates (rnm/dd/yy) Start date: End date: Work hrs: H a.m. H p.m.

Work days (Check all that apply) H Mon. Tues. H Wed. H Thurs. H Fri. H Sat H Sun. to H a.m. H p.m.

PRE-PROJECT ASBESTOS INSPECTION

Inspection date(s) (mm/dd/yy) Inspector name Inspector DHS certification No.

ABATEMENT CONTRACTOR INFORMATION

Company name DHS Certification No. & Expiration Oate

Address Contact person name Office Telephone No.

.(

City State Zip Cellular Telephone No. . TYPE AND AMOUNT OF ASBESTOS See page 2 for guidance Location: H Interior H Exterior Total Amount of Asbestos

H Friable - Submit notification for: H <260 linearfeet H < 60 square feet H <35 cubic feet I

H Any amount of asbestos in residential buildings with fewer than 5 units ‘ Linear Fee

Type: H Pipes/ducts H Surfacing U Dtherfriable ACM:________________________________________

H Non-Friable -Submit notificaticn for asbestos projects invclviig:

U looring: H Any amount, intact manual methods, or, U <160 square feet. mechanca chipping . Square Fee

H Roofng: H Any amount, intact manual methods, or, H <5.58c square feet, Dower-sawingH Siding: Any amount, intact methods only

El Other non-friaDle ACM: Cuoic Fee

FEES See Page 2 for payment methods, See Instructions Page 2 for more on fees H No fee required Fee ReceivedH Original notice, 2 or more working days H Sub-project H Revision, less than 2 working days H $50

H Original notide, less than 2 working days H Planned renovation project notice H $100

PROJECT NOTIFICATION AFFIDAVIT--lam an authorized representative of the abatement company named above. I certify that theinformation provided on this form is correct to the best of my knew]edge and that this project complies with Ch. OHS ‘159, Wis. Adm. Code.

SIGNATURE— Authorized Representative DHS certification number Date Signed’
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 tof ACM but less than 160 square ft

less than 260 linear ft, or less than 35 cubic ft Notify OHS Notify OHS

Removal of 160 square ft ormore, 260 Iinearft or more, or 35 cubic

ft or more of ACM No DHS notice required t Notify OHS

Enclosure,encapsulation or repair of more than 3 square ft or more

than 3 linear ft of ACM Notify DHS No DHS notice required_-

*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 tnotice working days tnotice 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
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 DHSunder 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.
p

y 

geable 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.

DNR.

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 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

Notification

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. 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.
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 Notice 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 Signed
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.
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 a leadbased 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.
Ca

p

j

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 an onsite 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.
STATE OF WISCONSIN

• County

Inthe courtofthe

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

Court
Preparer: Date p

p

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. 08103109
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 Signed
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.
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 a leadbased 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.
Ca

c

p

j

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 an onsite 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.
STATE OF WISCONSIN

County

Inthe courtofthe

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

Court
Reviewed h: Initials/Date - Draft Initials/Date — Comments:

(as appropriate): Review Final Review

1 2

Env. Health Specialist: I

Env. Health Specialist:

Regulatory SpecialistOther

A & L Unit S’jpewisor:

BEOH DirectorLegal Counsel

(Return to Fred Johnson) rev. 08103/09