HomeMy WebLinkAbout1996 Oct 23 - Lead Inspection/Surface Assessment Forms J
_� �`� Lead Inspection/ Surface Assessment Form
Sarnstabie County Health and
Inspe odA en ' Pnge / of_�
�Envirdnm`�ntai Department �e'c�t, usea•
Sunarior Court HouSB �p ll �O/GI�
� N S ex irarion date
License Rarnstable, MA 02630 �Ray�uorescence �
vtodel�Seria!#���
Address Apt_# City
� /Y�a�� I �1�� T�,�/l 1�,��f-
Child's Name(Last,First,Init) Birthdate('YI/D/� Ses
D � r , a.� / db / (o �
ParenU Guardian's Last Name PazeriU Guardian's First Name
C�? � a v ,-� I I I /� 'I � S �— I I I s�noie F�ly ❑
Owner's Name: �
f —/� Muiti-Family
Owner's Address: vumber of UnitS —
��� � Y U �
KEY: cov caov°er�ed e arlcs/Caiibration: � . /.�- /.3 /, i� /:�'
oia aiaaea J.S'3 s�.,# �•� /.S /..� /, � i,�f S
=�C encaosuiated Q•O 6. 6.Q -G. O.J d,L-O,/ O. d
n41 mada�ntaet . �'� S�n / O� � O f�
NA not access�b�e .
NEG negative SCales:(scores of 0 or 7 pass,scoras of 2 fail): �
POS positive
PRE prepa(ed � Surtaee/SubauAace 0�no peinv aA peint intact 7�ct OX paint mt intact 2»tOX paint nat intaCt
REM removetl Subsvate Q�inteG 1�.<tOX�eedsrepair 2�atOXneedsrepair
� REP replacement i�;�TapaTes[ p�„o cmrtwvea �=<�n�
REV - revef5@tl Paa' Peint rarmvad 2»f/16'pain[ramove�
SCR scrapetl to bare subsVate X-Cut Tape Tesi 0�no paint ramoveC t=etnG paint removetl 2a>V15 paint removed
Floor� Floor:
� � � � � � � C i � � � � � � � � � � � � � � � � �
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-�- -�- -'I > i ��.t. - _ - -� - - - - - - - - - -; - - - - - - - --� - � -� .
A (street side) A(street side)
Pb (lead) more than 1.2 mg/cm'- with x-ray fluorescence or positive with Na,S is Dangerous._
Leatl Hazards? � �.�+tort+o�lence
INSP. DATE (Y or N) REINS?. DATE �.,,,,��,o,�,,,,
� ,,o ;�� ;y ,� , y ► � � , � � � , ���p��
a.failed
Inspector
� REINSP. DATE i ' '"c o��ance i.m comp�iance
z.�.ro,K in a.oqress R El NSP. DATE � z...onc�n p.oqress
� t I I � 3.reoccuPar+c� . � � �.reoocuo�++ry
� I � i ( a.lailed � � I s.taJed
I
in ComplianCe
REINSP. DATE Fuli Compliance Date
2.�r1c in proqrese
Ii J.rexcuPancy
� a.latleC I I
�1
Inspector
Did you comptece a,urfsce assesxment form for encap�ulucion'? Y or N
L
�
EXPLANATION OF LEAD INSPECT10NI5URFACE ASSESSMENT REPORT FORM COLUMNS
:<.*�::�>;:::<::::»<�>':>:«:::;:
;;;5�t3E����:w::`:<;�;�«:::�<;;<�?< Refers to A, 8, C, or D side of dwaliin unit Refer to diagram on cover sheet
:�.<<:><.���::;°'�'::'<.<;�:.>:'�.;<::: 9
.;,�,.;;�`:.... .�;.,::.:....;... .
:::.c_::.�;�..:.�:�z<:,.+::=::>:;:�;.;>�:->:�>:-; -
:. �.............::::..
;;;�:Lk��£���If:�;;;:';':;;':;:::`::>: Refers to architectural element(s) being tested. If two loca6ons/surfaces are listed in this column, subsequent
,..,.:.:..:...<.<,..�::;.;�::.::.::<:<;<:::<:'
>:����'�::>>_��<><:;::<:;<> columns will be subdivided to provide spec�c information coResponding to each surfaca.
.:�`�:;��\�?:.`:��`_:..;; .
�':i:�:::.ti�.:"<c:�:�S4`;:::'-y`;3i3i�:%2i';:'2'`:;`:::
:�1;:::-'`�.,�;�.
-\...�..�:.R:::i:?:;::::�::_:::::.
"�` ������`��'����`��~'������' The actual lead result A numericai reading indicates that tt�e surfacs was tested with an XRF analyzer and a
����:::;�:�e::�«.:>,:�:>:;;:<<::<:>:
.���s:,,,ss:.;;»::;:.;:.:;..::<::
':::;;.s::�::>;\:::<:"::::<�;:'::><%:;:''z::::»:': '
_........... * reading(or average reading)c�eater than 1.2 mgkxrP indicates a dangerous level of lead. A`pos'or neg'notation
::; .. ..;;..>;:.>.:>;;:>;:::::<::<>:::::::::::::;::;::
:�;;:"'::::<:.,>.,;:::;:;:>:::;:;::><>:::..:::::::
<;�<:;:;:�>:;:"`��<::=:::<:>:::�::<:;>:<:<::::;:: indicates that the surface was tested with sodium sulfide, and a`pos'nota6ort indicates a dangerous levei of lead.
:.,.:.
..,..::1�~:c::i::`:%::iici�:`.:::i::
r
>�:�::�:..�.;,:.:::.�::>:::.:�::.�:::. �ach loca6on tested must have an individual result recorded in the`Lead'coiumn.
':::.:�;
;�L;:`�:>::>ti�<:.:;;��:<;:�:>'�:>::::s:':»<::»::�:::':'':::
::::.:.:::::;::..::::::::::::::::::::,::. The`L'(loosej column indicates the condition of the painted surfacE(s)tested. A checfc mark(.�or`yes'nota6on
..::•::..:::..:::::::.�:::::.
�:>��:::::�`:::«_::=:::<:��::>:�:�:«::>:::::::<:: i e surface s tested ' lumn is le blan o
n this column means one or both of th ( ) is not intacL If this ca ft k r has a'no'
- no ' s uestion is intact o e(ea e u a e in viola6o re ard
tahon it mean that t�e surf s in S m d d s rfacas r n less of
their
� � � 9 9
s a ' e ain is not in ac
condition•othe� re in vioia6on onl 'rf th t t �
- . Y P
Y
>`���::�8'���:�':�::':�`:;`:�:<:,::<::::>�» er can be correc ed b
,,._.�„_:,,,,;,..._.,,:,,, The owr abP(owner abatement)column denotes wheth or not a surface in violation t y a trained
�::::;>:::::��'><;::;::�:<:»;>:::::>�::::::�:�:;:<�::': owner/a
..,,_:::„,.:.,,:_,__,:.,.,:::,::::::.,_. homeowner/agent wfio is not a deleader. A tijes'in this coiumn means that the trained gent may elect to
:><:::::>=<::::_;::�:€<:>::;»<:::<�::«<:�::>:::::<:::::
delead this su�face by perfoRning one of the specified low-risk deieading activi6es. A`no'in this caiumn means
;...>.ti::.t>:__;:.»r:�<:::::<<::;:«::«__:;:<>;::::::::'
<;:,:;:
.:;.;;;:,:;;:;:;:;:.::.;:.;;;;;;::;;::_<:;;;: that only a licensed deleader is permitted to delead this surraca.
<::::>::::�.�<.:::::::;:<::'
�::::�:�E3��#�R�.:::;::.::.::::. The`dlr srf prep'(deleader surface p�eparation)column denotes whet}ier or not a deleader is required to prapare
>:<;:::<:�::<:>:::€:�:;::�>:::':::::::;>:�:�:::::::':::«��>:€
a surfaca in advance of it being deleaded by a trained homeowner/agert performing cartain low-rislc deleading
:::i:i::i::::ii::::i:-i:i�i:::::•i::::::�::::i::i:<::vf:r:v:i:ii::
activities. A yes'in this coiumn means that a licens2d deleader must be used to perform surface preparation if the
low-ri ac� i selec e 's e a su a'o or coverin a fricfiontm u with loos�lead aint
sk hv t d i nc i t� n act s rfac� .
{Y 9 P P
P
>::>.5.:;>::>::::::<::::::<:;:::::::=«:_::::<:::_:;..s::><:::«:;:>': '
:Ef�S�S1��€::::.:�._::.:::: The `surface/subsurface candi6on calumn denotes the condition of the paint layers with respect to potentiai
- - . .
eli ibili for enca suiation. Surfacas/subsurfaces rated a 2 are ineli �ble f r enca sulation.
i o
9 tY P 9 P
>�:���I��;�-��><�:<.:';:::<:;,:::::::::.'
....:::�1;.:.�;::.:;:::.:.� The`substate condition'column denotes the condifion of the base substrate(i.e.wood, plaste�, metal or masonry�
e ' u
.
with re ect to ot nhal eli ibili or e ca suia6on. S bstrates ra ' iole for enca su '
f n fed a`2 are ineli lat�on uniess
SP P 9 �Y P 9 P �
the substrate is re aired.
P
:;:��'�`.::::;>:.:._::;.:.:>;::<:��;::��:�`:::::»:::>::::
.:.::�.._���.."��.:._::::::.�:::. The results of the initiai tape test(s) required for encapsulation are recorded in this column. Surfaces receiving a
'2'on the ini6al ta e test are ineli ible for enca sulatio�.
P 9 P
:<s�`�S:�;�<:';:>'<:;;<;:;:::<::;
:;�f:;-f:€�;'��...�'::.::::::.::::::: The results of the optional x-cut tape test(s) performed by the inspector are recorded in this column. Surfaces
re i �
. .
ce vin a 2 on the x-cu ta ' eli ible for enca
t e test are in sula6o
n.
9 P 9 P
`,�,.'�E�1,�: <'':>:::::<:;:'::::<:'':::';
«:;CC��IIf1t1......�5.:.::::::.�:,:::: The'comments'column is for other observations that may be relevant to the deleading of a pa�icular surface
::;.:>.:�,;:.;:;::>::<:>:<:��::;':>::::�<: . .
`::;5�..�,-,;�;��1C1��;:::._: The`suitable for encapsulahon column indicates whether a surFace is potentiaily suitable for encapsuiation based
on the resu(ts of the ins ectors evaluation and an a e
t testin e 'indic e a
P
Y P
9P
rformed. A es at s th t the surface can
::;>,�:�;:>::`::<�;:::::<:;:;:>::>:>:::::�::�:;
�Y
be further evaluated b X�ut ta e testin and a c t '
t h esUn ; a 'no' indicates that the surfaca is ineli ible for
Y P 9 P 9 9
enca suia6on.
P
'::�=:=>:;::
':;E}E�:�>�;���':"':::<::::::;��: h `
T e delead date'column indicates the date that the surface was determined to be in fuii compliance with the Lead
aw
L .
�:E�;�:��`}�QT�::;:::::: The'delead method colurrn indicates the method b which ea
y ch surface was deleaded ko full complianca with fhe
Lead aw R f
L . e e�to the' e o a
k n the cover e for me
thod codes
Y� P 9 •
C'�WPSO�LEA019951fORM51Ll S0.FRM � � �
; !��3�,t��4'dqunty Heaith and LEAD INSPECTiON/ Page.�af�
� . €hvitonme�tai Depanment SURFACE ASS�SSM�NT FORM
Su�erior Court House • �
Bamstable, MA 0263Q
�ccress of lnscec5on: ��(� /��1./� S� �t T City Ct�'��p/J�--�
�CGM
�iCE lCCr1TiCW L�aC l CWR OLR SftF SUR/ Si;BST INITIAI. Xti.UT C.^•MME�ITj St11T for DE��� pE��p
SURrACc A8T7 FRE.� ( SUBSUR COND TAFE ( TE�T I I ENCAP? I OATE� �,fEi'r:cp
�l:o walls�Low waiis � ./ .z
I5asemarc'siCyair 2ii � � •(p I I � I
Coot � I I
Ooor�sing/Jamol I
L� I I I I
� Ooor casing/.lamo� I � I '
Qcar I I I I I ! I I
Oocr singf�amo+ � I I I � I
Coor � I I
� Goor incJ.;amoi I
Windew siil � � . I I f I
Win qsinglApron a.
� � Win headet/Sto¢s - I
Win sashRvtuiGons � I
�t siillPart bead I I
_ Exf sice sasn I + I
Wincow siil ( �. I I ,
/� � Win casing/F,cran, I . 'f' I I I
�� WinheaceuStcas� �.2— I I I ± I I (
'Nin sashltvluilions� ( � ( � I I I I I
Exf siil/Part be2d, � I I I
rxt side sasn I I I I I
Nliracnv siil I ( I I I
'Nin czsing/Acrcn� � � �
�l I
'Nin hez�er/5tcos+ .� I ( ( � (
Win sasn/Muilions� .Q I I � (
�1 siil/r'art�ad) I I � I I I !
Ext sid2 sash� � � I I � � I I �
IYVinccw siil I I I I
Win inglA�rcn+ I I I I � � I I I
'Nin n cedStccs � � �
Win s rJMuilians I I � I
Ext s UPart bead� ( I
� r side sash I
C:cset wails I I � I
C intenor coor+ ( I I I
C1 sing/Jamo+ , (
� C;bas reslF�oot+ � I � ( I
� C15 eiOSucccrts� I I
�Raciator S � �,�
�F�ocrrhresnoid �
CailinglC;oset ce�iing
L!CENSc� C.-� O �� DATE D ��
SI � TURE
,�, �8�i�@d��funty Health and �D INS�ECTiOPU Page�of a o
' ent SURFACE ASSESSMENT FaRM
e
Bamstable, MA 02630 �
.ac��ess of Insnec�on:�� �" /��lf/� �� Aot T City �.�'t�/yL�//S�D�iL--
RGO�i � .
Sti;E LCCATICW L aC L WR OI.R SRF SUR/ Si1g$; INITiAL X-:.UT C�MMENTS SI,IZ ior DE.�4 CE��4D
c v ' �
SURF,�CE �i8T7 ?RE?7 � SufiSUR , COND TAF� 7EST I I euCAP7 I DATE� 41Eir'CO
�b������� I I I i
���+� 14 I I
� oo«
I i I
Door psing/Jamb I I (
G°°r •� � � � � �
GDcor casinc,lJamb �6. � � I I � I ' I
e� I I I I I I I
D r casang/Jamb I I I I I � I I
Door I I I I I ( I I
�?oor casingl.lamb � � I � I I
Window siii
4Vin casuiglkpron .�
► ) Win headenSt�s I I
L.J � �
�� Win sasfvMuffrons
�� cxt siiUPart bead � I I
_ Ext side sash I I � I
- Window si I I I
� Wi casing/f�ron I ' � I � I ,
'�� �������I 1 I I 1 I I I i I
'�� �s�+u+��a� I I I I I � I I I I
= S���a��� I i I I I I I i
Ezt siee sasn � I � I
4Vindcw sii + I I I I I
'Ni casinglApron I I I I
`Nin heaCerlStcos f � I � I
Nin asrtlMuifwns� I � I f I I
= siiUPart beaa� � � I I I � I �
t side sash� I � ( I I I � I
1Winacw sill I I � I I I I I I I
'Nin psing/ADron� I I I I I
'Nin eader/Stccs I ( I I I
'Nin as'r�Rvluilions � ( � � I �
siiUPart bead I ( I
Ext side sash� � �
C:oset walt � I I
lintenor door
casing/Jamb
Ci ba res�f?ocr � I I
C1 helUSucoorts I I I
RaC.iator I � � , I
FioadThreshold I � I
CzdtngJC�oseS ceiling I
I
UCc!�lSc x C.�-��"� OATE /d � �
IATURE
_ ' B�� s�����e��nty Health and �,qp�NSPE�T10N/ Page�of�0
�' Envi$nmenta Department SURFAC�ASSESSMENT FORM
upenor ourt ouse �
arnsta e,
�
address of Insoec5c�: ��P p r��Gl�- s� Ant T Cit`/ y�iy�.-�U,C�.L_ _
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S1QE LCCATICW LE�D ( L �WR DlR SRF I SUR! SU6ST INIT1r1L( X�UT i CCMMEVTS I SUIT For IDE+.�L� Gc'���+D
SURFACE A6T7 ?RE.� SU6SiiR CCND 7r1PE TE�T , �A1CAP? pATt I 41Ei1-�Q
l.b wai}s�Low wails CO ��• ( ( � � �
6aset�oards/C:iair rail (�, � �-
� c�« p; ' � ,i I (
Ooor�sing/Jamb I
Co°°� / i • � i
t�oor casing/Jamo I I ( I
� ocor /' I ' I � I �
vcor�sincJJamb � � � I +
� �� . �� � . � � I
i7ocr c�sincl�amo � � � � I
� Wiraow siil ,' I I I
Win qsing/P�ton .Z, � �
�1 Win headerlSias p, '
Win sastvMuifions � I
Ext siiVFart 5ead� I
Eei sice sasn+ � I ( �
- Window siit I I I I � I �
�� Win casina/A�ron � � I I I I I �
'Nin ne�derlStccsl 0• I � I I I �
'Ninsas:JMuilions �. I I I I I � � I I
�.xt siiliPart�d� � I � I + I � I
�� �xt si�2 sasn) � I I �
'Nindow sill (5. I � I � I �
Q)� Win casina/fwrc� . I I I � I �
'`� 'Nin neaCerlSlccs ��j I I I � �
'Nin sashlMuilions� �.�I I I �
�t siiVPart tead{ � � I I � I �
�-- F�t sice sasn� � I � I � � I � �
�Winocw sill �• I I � I � I I ( I
� 'Nm czs+nc/Pcron� I I I � � I I
'Nin hezCedStccs I � I
( /i 'Nin sasivMuilions I � I � I I I
��
Ezt siiUPart oead� I I �
� cxt side sash� � I
C�cset waiis /� � I
C�inten r doot+ �
Cf casi Jamo, I I I
Cl hase�oa 1Fioor+ I � �
C1 snei( uccorts�
Raeiator I
I F�oorlThresnald �
CzdinglCloset ceiiing
�� r � ro.v .
� � -�3 h�v� J�e�� ��Pf�
uc�ris�x ���� oaTE �� � b
URE
/
�= B��t�`�.,���nty Health and �� �NSPECTiorU Page�of��
nt Si1RFAC�ASSESSME3JT�ORM
Bamstable, MA 02630 �
,�cc;2ss af Insnec5an: /t0 !� /�YZQ(,y�-� Ant m CitY y�p%vyy�r_�r/���--�
ROOM �iDd M
S1GE lCC?,TICW LEAO L OWR CLR SnF SUR/ SUBS i WITIAL X�,:1T C.^,MMENTS SUIT`or CE� Cc^•.�AD
( SURFACc { ( ABT7 PREr'? � ��:�aSi1R C:.ND Tr1PE I TE�T � �NCdP7 I OA�e� MET1-iGp
�l.b vraltsAow wails I I I � I �
�6aseboareslCtiair rdii � �
� �� I o a I
Coor psingl.amb a.� I I I
� �� D ' I I I I I I
Ooor qsinglJamb I I I ,
� C� � � � � � � � � �
C casingl�amo� I � I I � I
Ooor � � � I I
casi�c�'Jamb ( I
winoow siu 7,' I I I
Win cxsing/Ao�on �
�� Win headest52as I (
'Nin sash/Mu(6ons I � ,
Ext siiVPart 5ead � ' I �
E,.�t siae sasn+ �� � � I
- WinCow sili I I �) � I I
Win casing/Acron I � I I
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Bamstab?e, MA 263 �
�ccress ef Inscec�on: C(�� Aot T ��tY -
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w�srii �d.1 � � � � �
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�r,vimnmanta� fla„parrme�t SURFAC�ASS�SSME?JT FaRM
Sii�Arinr ('n�irt Nn�iSe
B�mstable, MA 02fi30 �
Acdress af Insaec;ion: ��� /'�')Q�li}--,.� Act� City • /�v7L/�iOG��--�`--�
?A�rR00M �
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. �nv���r���i�l Depar�ment
SUi�FAC�ASS�SSMEPlT F�RM
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„cc�ess oT Insnec:ion: ��o � � � /�Ll�`� Aot� City �GG�I/}���lJf�--�'
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,1 � '
l.10ENS'c� DATE /" "` � �
ATURE
�✓8�}�P.f���.�fiYity i;eaitn and �D INSPECTION! Page��of�g
r.t Si1RFACE ASSE5SME3VT FORM
Barnstable, MA 02630 1
Acdr�ss of Insaec�on: /J'� 4.c�-y..� �t T C;ty • ���L.sC__jj�Z�/
BATFfR00M� ��GI ��/G' D/' •�.i G�' �ty- �3' � Gi�-� �_
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SURFAC� ABT7 PRE?. �iJ3SUR CGNO TAP� TcST E�JCAP? pATE 41EiHOO
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Baseboares/CC�air rdu
Door I I
Coor casing/Jamo I
Coor � I I
Oocr casind�amb� � �
Windowsill Q. � I I I
WincasincJApren� p, C� I I , - - I
� Win hezdeu5tcas � � I
Win sasfvMuil'rorss ' 1. ' _:
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cxt side sasn � I
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Win sirglAcro�� I �
Win eac:er/Stms I (
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l:. cz�inetsvraiLsl I f I I i
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`�.� _ -�- t SURFACE ASS�SSMEi�IT FflRM
c.. . r„ �.r Lini�ca
�arnstable, MA 02630 `
.accrass of ins�ection: �,(O �' ���„� Apt� City �Lz�?�-r�.r� U�-,O�
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i base�oaresrFiccr+ I ( I I I
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�'' �� nt SURFAC�ASS��SMENT FORM
Bamstable, MA 02630 .
Adcrn.ss of Insoection: �(O� L�%�� S'�" �t� City y�C/I�X-�U�iL���
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S i AI RC,�Sc I^-P,G'f/l�
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sice sasn� ( I � � � I
C�ose?wails I I � � I I
Ci intetior ccor� � � � � � � � � � �
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inspecior/Agency�����,r R`�:j,� a�ja LEAD INSPECTIONI Pag�of ?�
���� �� SURFAC�ASSESSMENT FORM
, ment
� ���nar�nr !".,��.. u_..Se .
Barnstabie, MA 02630 �
Addrr,ss of Insoection: �(O � ���'� Apt# Citv � v jL,L�
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sTaiRc�sE /'���' � �v 5—�—
SIDE �OCATiCW LE�1D L OWR OLR SRF SUR/ SUBST INITIAL X-CUT COMMENTS SUIT for DEL�1D DELEAD
RFACE ABT? PRER'? SUBSUR CONO TAPE TEST ENC?,P7 DATE METHCO
l.b wallsiLow is CQ " ���j%
Baseboa '
Door ;� '
� r qsing/Jamb �
Ooor
Ooor qsing/Jamb
Door
Door casiag/Jamb
Door
Door casinglJamb
Door
Ooo�casinglJamb
Cc�or
Door psi Jamb •
Windew sll �
Win singlAproo
� header/St
� in sas ullior�s /, �
Ext silUPart d
Ext side sas
-- Window sili
Win c2sing/Aprori
Win headerl5tocs
Win sashlMullions
Ext siiVPart bead
Ext side sasn
Closet wails
Ci interior door
C!casinglJamo
CJbaseboardslFloor
Ci shelf/Supports
Newel post
Raiiing cap
Handrail
Balusters
Lower rad
Treads
Risers
Sinnger
Ra�ator
Floorfihresfiald '
Ce�ling/Closet ce�ling
L10E1�1SE r��Q d E'-� ' OATE�Q o�� l �
SiG� RE ` �
IEI�s�4?�unty Health and LEAD INSPECTIOW Page�of�
�'� Environmental DP,�p,f3(tment SURFACE ASSESSMENT FORM
' Suoerior Court House
Bamstabie, MA 02630 �
Address of Insoection: /� �,���v�v Apt# City �Q��-yL�r, S[��0o/'7`
BATHROOM ��a�� I
SlCE LCCATIG`W IEAD L CWR DLR SRF SUW SUBST INITIAI X�UT COMME�ITS SUIT,'or DELEr1D DELEAD
SURFACE ABT7 PREP'? SUBSUR COND TAPE TEST ENCAP? OATE METHOD
uP wa�Is/Low wails � L o.
Baseboards/Chair rail
� o� 3
Door casing/Jamb
Door
Door casing/Jamb
Window sill Q �
4Vin casing/Apron _ -
GWin headerlStoos a„f
Win sash/Mullions ' p`?, -'
Ext siiVPart bead
Ext side sash ,/ -
Window sili '
Wi qsinglApron
Wi headerlStops
Wi� stvMullions
Ext iiUPart bead
side sash
Uo cab fra xr
Up inets walis
Up shlvslSupo
Lcw cab fra eJDoor
Low inets walls
Low snivs/Suoo
Cioset walis
C intenor door
Cl sinalJamb
Clbas ' rds�Fioor
Cl S� ��SU�OrtS �
Sheives
Drawers
Radiator
FioorlThresho d
CeiiinglCtoset ceiiing
� UCENSc� ��=--y�-- OATE--��-��
GNATURE
Ins�f��lRyCo�nty Health and LEAD INSPECTIOW Page2Zof,��
� r"t�viro�mentai Department Si1RFACE ASSESSMENT FORM
� ' Superior Court House
Barnstable, MA 02630
Addressoflnspection: f�o� /����� ��'� Apt# City l,,r{�jy� � � �C�f--
KITCNE;V
SiDE IOCATICNI l�r1D � OWR DLR SRF SURI SUBST INITIAI X-CUT COMMENTS SUIT for DELEAD DELEAD
SURFACE ABT? PREP? SUBSUR CONO TAPE TEST ENCAP? DATE METHOO
Uo wails�Low vraits �.
Baseiward5/Chair raii
�7' � �6k.Sc�.
Door casing/Jamb
� D°°r fp q��. ;/l
Door qsing/amb
� �°°r ,�"/'
Qoor casing/Jamb
� D� fi
Door casing/Jamb
Window sill
Win casinglApron
O/ Win header/Stops
Win sash/Mullions
F�ct siiUPart bead
Ext side sash
Window sill
Win casing/Apron
,�� Win headerlStcos
Win sash/Muilions
Ext siii/Part bead
Ext side sash
Window sill
Win singlApron
Win h dedStoos
Win s sh/Mullicns
cxt IUPart bead
i side sash
Uo cao frame/Coor
Up cabinets walls ('_
Up cab shlvslSuCo �.
Lcw cab frame�Door
low cabinets wails
���sn�is�c� G.
Closet walis
C1 i tenor docr
G inglJamb
C!bas res�f!oor
C1she/Supports
StieNes �-
Orawers
Radatar
Fbor/f hreshold
CeilinglCloset ceiling N
5���'s Co�
�e 000� o��r�;'� n � a 3
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SIGNATURE �� ��
B�{��1����ty Heatth and LEAD INSPECTIOW Page2�of��
'..�: Envar,o�menta1 Oepartment SURFACE ASSESSMENT FORM
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Address of Insaeciion: Apt# City ��'`D v ��
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SIDE LOCATION/ LEr10 L OWR DLR SRF COMMENiS DELEAD DE�D
SURFACc ABT? PREP? OATE METHOO
Siding
Camerboards
Lower tnm
Upper trim �� x
o�� .`f �
� ' Door casing/Jamb�,S a,�=f 3;'
Thresnold
Door
Docr casinglJamb
Thresiwld
Door
Ocor casing/Jamb
Threshdd
Door
Door casing/Jamb
Thtesndd
- Window siil j(Jf�- '
J� / Window casing � (_
Win sash/Tviulliorts (�S L
Window sill nf�-
� � 'Nindow casing � L—
Win sastVMuilions �
Window siil g
�3 Window casing (� L.
�- Win sash/Mullions I 2
Window siil �
� � 'Nindow qsing � L
Win sasrvMuliions �
Cellarwin units
C211ar win units
Ceilar win units
Celiarwin units
Foundation
Bulkhead
Fences ,0� �
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ATURE
. R��S��/�'s�esso�/l��e�c�y Health and �EqD 1NSPECTIOW � Page��f�
nvironme tal epartment R1SK ASSESSMENT FORM
'�"'��u nor our ouse
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Address of Risk AssessmenL �� `� ��� `"�� Apt# City �/�-
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RGbM/ ICCATIOW LE:1D L OWR CLR SRF >25% SAFEGUAROS IC IC RECERT DE!EAD DELEr10
S�OE SURFACE ABT7 PRE?'? OAMAGc DATE METHOD DATE DATE METHCD
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Ins,.,-+@�mr�,A,t�h�County Health and LEAD INSPECTIOW Page�f°of��
w�� �`�nvironmental Deoartment Si1RFACE ASS�SSME�+tT FORM
' Suoerior Court House
Barnstabie, MA 02630
�cierEss cf Inscec;ien: L�� �'��� ��y[ Apt� City 7/Q/l�-v�n r���
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SlOE ;CCAi 1CW L=.aG I l I CWR I DlR Sr'tF �^.MMEYfS � OE�w.4D DE�+AO
SL�RFACc A8T7 PRE.�'? DATE 41ETi-Cp
Siding 7r� � ( � �
(Comerncar�s I C,�-S L I
ILewer;nm � � (,/ I
IU�oer'�nm /1/ � I
Docr (� (�
� Dccr casinc,lJamb � � � f
I Thresnoid I/I � I
Cccr � � I I
Decr casirr,.lJamo I � I I
Threshold � � !
Docr ( I
Ooor casind�amb I �
Threshdd i
Ooor I
Docr cas�nel.;zmb
T'hresiwld I I
Winccw si'tl n� � I I
CWinccw casing I I f
'Nin sasrvMuilic�s� � I � I I I I
yv�� �,�� ( I I I I I
'Ninccw casing I � I � I +
'Nin sasvMuifions I I I
Win sil I � I
`Nindow casinq � I I I I I
'Nin sasvMullions I � +
'Nin siil I I I I
'Nincaw qsing I I � I ' _ I I
'Nin sas�rMuiiicns I � � I I I
Ca!12r in urics ( � � f I I
�Ca!f2r in ur,its � I � I I I
ICaitar in uniis I I I I � � I
Ceilar i�unds (
IFoun tion I
8uikh d I
Fenczs � I I I
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I i / n LEAD WSPE�TIOW Paga�o�
'�_�� "�,g4��'ounty Heaitn arc SURFAC�ASSESSMEidT FORM
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Bamstable. �:1A �^�^� ,
Adar�ss of Insoecticn: �(�j� ����,._ Aot Y City ���jy,� ���>j�����—
�=cIOR D si ��
SiCE ICCATiCW L�4D L OWR OLrZ SRF C�MME�ITS OE��40 OE��40
SURFACc I�,con 3hcv/ A6T� I ?RE�? ( DATE M�i;CO
Sidin9 � �t /J � 1-� � � �
Comercoards �
Lawer trim �
IU[per tnm ��- I v I
Door
. Ccor casinc,/Jamb ( I �
Thresnold I � , I
•� o�� � ' n i z I I I
v � Occrcasir,e�,;amb I� s � I
t�Ct�nL�i`� resnald n y I
000r sh 2 � (
� � Dcor casirscJ.tamb i
�hreshdd I
Door I (
� Door psmg/Jamo � I
Threshdd ( I
- IWindow siil I J(f�- � �
�� Windcw casing GLS I1-- � �
'Nin sasi^dMuilions� �'� ' I ' I
D� Wincaw sill I I � I =' � I ( I (
Windcw casinc �� � � I I
IWin sasivMuilicns � � I I
/ Wincow si(1 I I -t'
C Window rzsina I !� I T I + (
'Nin sasnlMuliions I ( ' � �
/� � WinCow siii I �� I � !
yJ I'Nindcw czsing � � I � I
'Nin sasrdMuilic�s) I I C.. I I I I
ICai�ar win urits �A- I L- � ( � �
Ca:la win uniis I I I � I �
ICaiia win uniis I I I !
Ceila win unrts I � I �
Four tion I I I
�Buik ead � ( I
.a F��� � I e9 I-�- i I � I
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���4���e�c unty Heaith and �D INSPECTIOW Page�of�
�,° SURFAC�ASSESSMENT FORM
� ent
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Barr,�t�b'�, h�'.4 Q2�30 / /_4 �' � /��
Address of Inspection: cP Ant# City y 1�,� �1y�/'L�—
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SiDE �CCATIOW Lc4D L OWR DLR SRF COMMENTS OELEAD DELEAD
SURFACc AST? PRE� DATE METHOO
Siding
Comertioards
lawer trim
Uoper tnm
Ooor
Door qsing/Jamb
Threshold
Door
Door casing/Jamb
Threshold
Door
Door psing/Jamb .
Threshold
Window siil �' S
�� Window casing =
Win sash/Muilions /) 1
� Window sill �$ �
� 5 wndow casin9 dS 1"'
Win sashlMuilions h e` 7'
Window siii �sh
.,,� /p Window casing (�
Win sastvMuilions L
Win�ow siil
Window casing
Win sasn/Mullions
Founoation
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