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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 � � � � � � � � � � � � � � � � � -�- -�- -�a- -�- -� J_ .1 _! _ 1 _ � _ � _ �- _ L _L _ _I_ 1 I � I ' C � � � -L - I I 1 i � I -IL t I I 1 I 1 I I i I I I I I I I '! I -r -t- -i- -t- -t- ��YI�T - t - r - - , -� - -r r -�- -i- �- � - - - r - r - r -r -r - i i i i i i i i i i i i i i t i i i i i i i i -� -�- -� - - I - I � I� � I I � i_�/ . I I � � � {,�f� � f. f I I �. ::i.- ��-� -� - -� -r �- -i- -�- - � - y - '��=� - r -r- - -r- i- � L- -r- -+- - � + ..�.-` �� 7 _� _r, _ -f- - _� � I � i..G,i��_i_ i i - -� -�- - -�- �- -�-��-�- �- - i i _ i _ dLi _i �- - � �- i i i i i; i � i i i i t =_+ ? i i ' i - -� -�- -�- -�-'t�-'�- -����� -�- -� - -�- - � - -i - -� - i i i i .s. i i � .� Qt�w I - -i- -i- -;- -i- -}�-_�,., � ` i i i 'i ' -i - -i- , i -i- B �- -'- -:_ _i_ ��9 �^Z�_ 1 _ L _� _�D B� i_� �. J_ _ 1 i ���_ _�� � � � � � � i � � i � - r i i i i R� �. � i i i i � r i - - - - - - � - � - r - � - � -r - -r r -r�j-� -i- �- - -t � - r _� r - -r- � i i i _i _ Lt _ 1 ! i _i_ i i i i i i i i i i i F -� -�- - - -�- -� I �1 1 � 1 �{ I i I I I y!J/1 � f I � I I I I I 1 _r _I_ _ _ _!_ _I_ .r _ � _ ;��-4��` _ � _r _ -t- i�-*F^�l`�- -1-- ��^� t�t�l-. _ r _r _ I i : I I �I I ! I I I I I I I 1 I I � I I I I .� i I I -� -�- - -���f/ �' „ ' F ' !"����� !-�-� -i - -i i- -i- ,�,v'`-i- -i - `i � i - i fi - i -� -i - -'- -�- - - -��-�- �-l� 7�+ - - �'- ' -�- ��- -�- -�- -+- � + - + - �- -� -� -�- - � I i � � f` � � � I I � + { � � � � � � � � � t � � `� � -�- -�- -'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_ _ , ' :iflCM 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 i � Win heacedStc,�s� � � � � � � � 'Nin sasvMuiliorts � a � � � � ( � � � �.xt siillPart he2d� I � I I I �a't sic'e sash V � , I � � I Nlindcw siif ' I I I � I ( Win casinglAnrcn+ I � I �� 4Vin heacer/Sloos� ( L I ( ( I 'Nin sasn/Muilions� I � I � � � I t.�t siiUFart bead, I I I I � I I I �;sice sash� � ' I I I � I I � `Ylincow sii( � � I I � I I 'Nin sing/Aprcn� I I I � I � I � /a(l Win eadedStops � � �� 'Nin s shJMuilicns � � � � � eYt iUPart bead � � � SIC�R SdSh� � � � . CAset walls � I C intenor doorl C1 sing/Jamo I � C1 Fzs rds/Ficor I I ' C1 sh �(lSuc�oRs I I I �RacSacor Ffocr/itves;wld i � Ce+fing/C'�oset ce+iing I UCc^!S"c X��6�� OATE � �_"_� - ATURE , Bamstable County Health and ' ���q��,tal Department �F,qp INSPECTIOIV/ Page�of� , "` �uperior Court House SURFAC�ASS�SSMEM'FORM ' 'Bamstabie, MA 02630 �ccress of Insoeciian: /!a� �a�� -�� Ant� C;ty / G���'Y�-�dL<_�j`-J Hr1L�'NAY �/0 O �'� ��C� ICCATtC{V! L.�D l CWR DLR S�i. SIiRI SU6S i WITG1� X-C,:JT CC�IME:VTS SvIT fct CE'wA vEL=.aD c SURFACE c I I ABT% � ?R��c SU6SUR ( CCND I 7AFC I i EST cNC.;P7 � OATE� MEi HCp l.�walisttow walls �� � ( � � �6asedoar�Chair rail � � � � H � id. I I I I �J Ocor�smg/,:amo) ( � � D°°r � . � � � � � I � CoorcasingiJamb) I ��I �i � � � � I � I I � � i i I I I i I I � Oocr casinglJamo� ( + � ' I I � C°°r � � � � f � Docr cas;no/Jamb� � _ I I + ( I I J� J °°°` �' ,3 I I I I Ooor casing/Jamb � I � � �� .�I Ooor sindJamo, ( �4Vindcw siil I I � Win sinalApron I I I I I ( I " Win h derJStccs� � � � � ( I `Nin s NMullions� ( � I I � I I ( cXt s UFart�e.?d+ I ' I � � ' I I I = stce szsh� I � � I I I ( � Wirtdcw sii( � I I I I I ' I I Win inNAoron� � � � I ( � I 'vVin h derlStcos� � � � I � I I Win sa ;UMuilions� � � •� I ( I � � I �;�� �=�-a1 I I I i I I I = 5�Szs;l I I I I � i I I I `Ninccw siU � � � � � � � � � � � � � 'Nin a �nglAcrcn� � � � � � � � � �� � � Win h des/Stcos� , I I I I I I I I Win sa iNuiliors� I � { I I I I I � �i sii art bead� � � � � � � � � � � si�e sash � + I I I I ( I I I C;oset wails I I � Clintenor door) ( � I C�casma/Jamo ( I � ` � �i baseooaresrFloor � ' I � I I I CI shHf/SwCorts I � C:oset wa(Is � I I ( �i � Clinlenordcor I I � � Ci casing/.;amo I I I C;baseCoarc�Fioor ( G sheif/Su�ports Radator fbw/Thresfiold �nglClaset cetGng , UC'c�1S'c�r"�c3� OAT"t Sl URE ' ��fits°f���unty Health and ��INSPECTION/ Page�of�(� '� - �^`• SURFACE ASSESSMENT FORM ent ' e Barnstable. MA 02630 ` � / A�ress of insaec�on: /�p � ��Llj7� S7" Aot T City ��Q��yy`.���f�,� STr11RCAS� � _ SIGE �CCAr?CiV/ ��=AO � CWR CLR SRF Si;RJ SL;BST ,�ITIAL X-:,UT CCMMEVTS SliIT;`or OELE40 DE:.:AO SURFACc ( :�BT? I ?ftE?? SU6SUR I CCNO I TAPE I i EST I (c�CrP'� OAT� I ,N�HCO l.b wai rnv wails ! � I � I �8aseooar `air ad I I � � � r casinc,l.:amb I ( I �°°r � � � � ( 0 r dsinglJamb � + � ' � I I I �°°r � � � � ( � � D r�sinr,l.;amol � I I I I I C°°r � ! � � � � � � � D �sinc/Jamb � � I ' o�� 1 I I o �;�r.:�,o � � c� � � ���.�,b� . w�,�, ii � � ' in casing/Acron I ! I I _ in heacetlStcc.s � I I I � n sasrvMuiliortsl � � I ( � I I �Stll/F3rt J224 I I I � I � I � I .I �.:Xt SIQE 525ti+ I � I I . ( I I � WI�!'�G1Y I1� � I � I I � � ' in asin�JAcror I I I I ( in hezder�52ccs) I I I I + ' in sas.vMuliions � ( I I ( t SiiVPart beac1 � I I I F_xt side sash I I I I I I ' C'asei w ils � � � � � � � � � � G intenor door I � � ' � I I � C�casinc,l�amo� I I I I � I I ' I C1 sexar�lFioor+ � I I � I I I I I snelf/Succorts+ � I I I � I INewet past � I I I ( I �Rai6ng ca.� I I I I Nandrail � I $alusters , I �Lcwer rad I I � � I ����� n i I i Risets I I �Siringer � + I I Racator ! I I ! �Fioodihreshold " n I CnLng/C1ose!cesling n ( W /l CF,.�%`,2 � C� ��-9 /� �3 � - UCc'NScn OA7c!_�__7� " �G TURE ` , ;� �8arn o���ile County Health and �qp �NSPECTION! Page�of�-O �nv�rort�ie�ta! Department SURFAC�ASSESS�I+tENT FORM e , 30 ,�y� � ,;ccr�ss cf Insoec:icn: �6 P � �!�� �7` �ot T City � U,��--- RCG��i J (�� �i� C��� SIGE I LCCATICW LEaO I �I CWR ( OLR SRF I SUR! I SU6ST I INIT'�1L I X-CUT C�NMEVTS SUIT�ar IDE�=aC� CE��I) SURFACc ABT? FRE.� �L'SSL'R CCNO � T�1PE TE�T cNC.4P? OATr I A,1�'r.Cp l.ro wails/lcw walls i/ � � i I � I (6aseboareslClair raii � �(J I I I I Oaor � I ( Ooor cas GJamo � I I I , I Qoor � I I I � I �.'bor w ingl�amb I I � � I f Coor � I I � � + 1 � Ooor ingl,;amo. I I ( I Goor ' I � I 1 I Door�sing/Jamo I I I � 4Yindaw sill I I � I + Win casing/Acrca � I � t 'Nin headerlStoGs� � I I � Win sashRviuifions� (,� I { :xt siillPart bead� I I � _ �;side s�sn ' I � I Window sill I I I I I I � �J ` Win��ce�S cos+ � I � + I I � I I ' 'Nin sasvMuilicnsl I � ' I I I I �i siiUr'��rt bezd' I f I I � I ".�t sice sash � I I I I ' I Window sill � ' I � I � f ( I I 'Nin sinqlAcrcn� I I I I ( I Win CerlStcos� � � � � � � Win s s:✓Muilions) � � � ( � � � � Czt iiVPart beaa� � � � � � � � t sic�e sasn� � � � � �� � � 'vJ(nccw siil I I I I I � I 1 j 4Vin singlAnrcn� � � � � � � � Win�ez�erlStcos� � I I I 'Nin sNMullicns I I I I I I Ext iii/PaR bead� I I I • � siGe sash+ � I I ' C:oset wails I I I ' C intenor door� I I I I I C! sinq/Jamo� I ` � I ( I I C;bas tdsiF�oor� I � i I Ct s elf/Sucecrts� I I I � I +Radiator I I f , �Fioor/Thres Id I C2�iinglC�os t ceiiing � � eGt�' ✓J �'���Sj " (��� r- s �'�,'�-��,v J rs �-�-t UCcNSc.� ���� OA7E �� + IATURE • + ��Sa���unty Fieaith and LEqp �NSPECTtON/ Page / of�� �' ErS'Sironmentai Depariment SURFAC�ASS�SSMENT FORM uperior Court House • � Barnstabie, MA 02630 � a.ccress of insc.�ec5on: /j0 .� �Ql/L �� Aot T City . %G1�0 lJ�'�—J RCQM �Q 'L-e'C f' ozi7-��( ��G�' � S�Cc LCCATICW L...40 L OWR OlR SRF S�R/ SUBST (iVITiAL X-CUT C�MMENTS SLIT�or DE aC CE�4D I SURFAC� ( � I I A8T? I ?RE.�? I SUBSUR ' CCND I T.aPE � TEST I ��1CAP? ( OA� 1 ME i i-�Cp j�9�,�1����s �d. � .y � � � � 6ase5oarc's/c�ir ra;1 ( , %•V ' G �� n I Ooor casing!„amb I � c� � I I � I � o�«as���rJamo � I i I I I �Ccct + ' I I I I � I D casingl,:amo+ I � I I � I Door � � ( � � � � Doo qsingl�amb ' I 4Vindow siil J L',v I �J / Win dsina/Aswai 1 I � � I Win header/Stocs � wi(i SHS�UIrIOIiS nG� Ext sillfP�Fbew� � I I � ! Li1,nil ;xt sice sasn� � � � � I ( ' - Window siil 0.0 w I � � I I I I �� Win casing/ � �0.� I I I I ( ! 'Nin heacerlSlccsl �. I � I ' I � I I 'Nin sas�JMullicrts I I � � I � i + I " ° , , � �S;��xi c�l � I I I I i I ���� I I I I ! c.n side sasn� Windcw sifl � � � �� � � I I ' 'Nin casine,lf�w� I . I � ' I I I I f'1 `Nin neaCet/Stcps# � + � I � � I ✓ Win sash/Muii"wns{ I I I I I I ( cXt siiifPer!-eFde� i i � I ( I � I I Extsi�e sasnj � I � i � ( I WinCcw si� I I � I � ( I � I � I 'N n c2singU.nrcn� � , I I I I I I N nea�er�Siccsi I I I I I � I I I 'Ni sasrvMuilionsl i I I I � I � siii/Part bead I I I , . �xt s+Ee sash� I � Q ,Sh e/✓�'S� /o.� � � C{intenor door+ � ' ( I C!casinglJamo I ; Cibase`oards/Fiocr I I C1 shell/Sucooris+ I I i �RaCfator I � '.� F'�oorlfhreshold �. � �.-� I I Ce+iinglC�oset ceiling I ..Q n-,l /. � '�- 4�'S i 3�,'�w�� C����,�s o-C �/Gb / LICcNScX �a�/ �7 DATc /� � / � StG�t U E J �'f�q��unty Health and IEAD INSPECTION/ Page/�of� Environmental Department SURFAC�ASS�SSMENT FORM Superior Gourt House Barnstable, MA 02630 � l ,�c�c;ass cf Ins�ec5an: ,� � Act T City . / U�`,, nCor� 7 �� hf ��d �� S�CE I LCC�TICW LE�D !I CWR � CI,R S i S�'R/ I SUBS7 INITUIL XtiL'T C�MME�TS SUIT�or DE a CE��p SURFACc �BT? r'RE:� SJ6SUR CCfVD T`1PE TEST I ( =VC 1P? + OAT�� {,{�'�-;Cp j�.:��„��„���s o.L 6. [.t.. I I I i i ��asehoareslctiair raii %•0 1 ( � I c� ( y,� II! I I I � � Ooor qsinc+,/.;amo � ( I I � I G 'c� a.� (.y I I I Ccoc c3singlJamb� �.(o � ' ' I Deor I I � � I I � f � Ooor inglJamo! I I I � I � I � �C� I � I � wor sinc/Jamo I � � I Winoow siA f' I � I Win casin .� I I I I � �/ Win header .0 � I I Win saslvMuifions � � I Ext silUPart 5ead' ,/� ` � � � ( ( �t s»5��,� _t. � � � � I � � Wirccw siil .s � I � I � I Win casing/Acron�, ��. ( I � I i�� Win heacerl5� .O � I � I � I � ! 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L:CcNS'c� pqTF� S i -' -�' •' • •�- • � � � .• • • _�' • �♦ •' • - � •. •�- • •. • � • / / � �• i • • •- • / r ♦ — . � � � . . • ������ �• . . . •� . � . . . ��������� ��_ �s- _..: .. . - �����__��� _�— �� •.. , , :�.����__�_� _�_ ... � . . .����—__—� �_ ,� ... ������s� s L �.. .. . . .- • � ._-____ __� ��e�s���� �� � ... ... ..: . . .��������� ��� ... . � . = .��n������� ■��� ; ... � . . .=r�������� ��� ���� �������� ��� ���������������� �������� ��� ��� ������������ ��� ��������� ��� . •. . - ✓� �______, ___ � I , � � -•- •• ��������� ��� • !�=-- _-��l����� ��� - •--•������e�� ■ � '- - �J�� ��� ��� ���� ��� ■I�e�� ����������� ��� ���������������� - ���e����■�� ��� ����� ���� ���� -����������� ��� ���������� ����� ����� ���������o - - .. ����� �� �� � ��������� ���� �a���i������� ��� - - ���������������� - ��������� ��� _ . ... ��������� ��� _ . . .v��_•�����■� ��� .. c.�������� ��� - ... .r., ■ ���� ■��� - ����������i■■■■r��� .. �.�� -�- __� ,��������� ��� - . . .�r������� �� . :..:����������� ��� ����������� ��� �-... . �������■�� ��� � .. � �c�������� ��� � - ,i .. ���i������ ��� ,'l��.,. - .. . _ L �`�� � " � - - ��Barn�`ble County Health and �� �NSPECTIOW Page��f�O SURFAC�ASS�SSMENT FORM nvironmenta epartment . upenor ourt ouse Barnstab!e, MA 02630 ` ��������� .'�ccress of�nsoec�on: /( s/ f�Q,��� ;aot T Citv . .. rtc c L� � C�� (c� �e c M /��-f- � d �da�� ��E LCC.S7ICW ���p WR OlR..r2F SUR/ SiJBST INIT1Al X-.^,UT C�MMENTS Si.�IT ror DE i E�+.�p V^ I SURFACc `I A877 I PftE.=? 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SUSSUR C:,ND TAP� TEST ENC?,P'1 OATt� !viETt;Cp j�b,���s �a I I � i I i i �s����a . � � � � � Cocr 0 qsira/.;amo �.�.� I ' ( I � Y� � Coor � � � � � ( � � �� � � � � � Doer dsinglJamb � � � �G� .� I I � � � � � I Ooor�sinc,lJamb I '7,`,.� � I I � I Ceor � � � ucor casincl.;amo � � � � � � � Windcw siil � � � I � j 'Nin casina/Apron.,g,(� . � I I Win header/Siocs I I 'Nin sashlMuifwns /, I �n siii/Part 5ead � � I cxt side sash � �I � I � � I � w�srii �d.1 � � � � � YVin qsing/P�ron��,(, I,�I I �� `Nin heacerl5tcos� � � I I � I , I I 'Nin sasvMuilicns f I I I I I I I :..�t Stlf/Fart be2d i I I I � I I I ' I �S��Sas;l I � I I I I I I Iw�nocw s�i� � � I ( I f 'Nin casinglAcrcn� I I I ' I I I �� 'Nin a�vMusiiions+ ' I I I I i I � � + c.�t siiUPart Dead�n� I _ i I I I I I I I ( �t sice sasn� � ( � ( i I � I I 'Ninacw siil I , � � I I I I I � 'Nin casm Anrcn+ I f I I I I 'Nin nea rlSicos) I I I I � 'Nin sas' ullior,s I I I I � I I =xt sii rt tead� I � I ( txi ce h � I � I �C:osei wai(s ('e/ ^ �.(y I I I I I � nC1�J�Cl infenor door I I � ( � �/ C�casi�a/Jamo �• ( , � I � I C1 case�oarQsrFioor� .�+1 I I I I C�sne!flSuccorts� �a. i I I �Raciato� ( I I I I Fioodihresnold C�t"inclC�set ceiiing St URE UCE;�ISc',:�� O� / OATE /� _� �. ��:Src�9�dbunty Health and �D INSPE�TIOW Page of�� �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 � a n d f�U v�- /c-�'� -s'i d� S�CE �CC�iTiCN! l�0 � CWR Ol.�SRF SUW SU&ST iNITL1L X�,UT C:MMEYTS SL�IT!or CE��.40 DE_=?�D SURFACc I � A87� I PRE.� I SiJBSUR CCND TAFE ( TEST � I �NCAP?( DA i t i MEi HQD `Uo wailsrl.ow vrails �/� � '��, !1 �Baseaoares/C�airra�i ' p ..�'"L � I � Ccor Joor cas�nc,/Jamo�10•�� � I � � � Coor � � ' � I I Occr�s:�gJJamc � � � � Window sill :Nf}I � I I Win casinc/Apran� � I _ - I r"� Win header/Slccs � ' �_ ' �r.� � Win sashrMuilicns� ' I + � -' �`ii� � cxf siiVF�..rt beac�� �„j, :xt side s2sn � - Wincow siil ' Win casinelAcrc� � I I 'Nin heac�lStccsl � I I I I _ Wi�sastvMuiliorts I � I I I ( :Yt siiVFari bzad� � I Ex:sioe s�sh � � � � + IUc.:�D"nanefCocr I ( I ( � I I I Uo acines vriis+ I I � � I I �o�5��,s� � I 1 I i � Lcvr r,�iame�Docr I I i Lcw cabinets w2ifs� � � � ( Low cab s;vs5uco I ( I I � i f IC;052I`Y2115 I , I I C;int�br:oor� f ( I � I I C;c2sicclJamo� � � � I ( � � I I Cibaszoozrc�ficcr+ ( � � I I I I � I I I I C1 sneiBSucoor,s! 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I r��ta I I I I I I F!oor(fhreshald ' I I � Ceiung��oset ce+ling R- I � � Dv� P�. r7p 1.- �B �PP -sh�r� ��-�.. �����5�� ����� otiTE o 9� G� URE ` 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� -�1- z 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 UCENSc# ca�� y DA7E SIGNATURE �� �� B�{��1����ty Heatth and LEAD INSPECTIOW Page2�of�� '..�: Envar,o�menta1 Oepartment SURFACE ASSESSMENT FORM • uperior ourt ouse ams a e. �� � ��1�� � Address of Insaeciion: Apt# City ��'`D v �� �XT'ERIOR S �l.�2.� 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� � er �� ,� z 3 a,, � � (.0�S S �(/A v .� rn0 _3 t� ,DaS � � " r L;CENSE#���'�� _ OATE �v 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 e, 30 � Address of Risk AssessmenL �� `� ��� `"�� Apt# City �/�- � s,�d� ��' . 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 G , � (o � O.S c. • � � �!o �s � I L�CE�1Sc tt �c�/l �"9 DATE___.�/��d___,.i��� A RE � / 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��� =xr��t0� C -r��',e� 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 I c,v � S I r4 t L I � I i � I I I I i ' ' I � I I I � I ( � L�CcMSc z �c"�-if � g DATc t7 SiG,�T c / I i / n LEAD WSPE�TIOW Paga�o� '�_�� "�,g4��'ounty Heaitn arc SURFAC�ASSESSMEidT FORM • ent � e 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 .�s�d� , I..�' I� � ' � I I I I I I I I I i � I � � /' (,U � d � � I I I uc�r,s�� ��c1� 9 :�a,TE �� o���G -7 7 RE ���4���e�c unty Heaith and �D INSPECTIOW Page�of� �,° SURFAC�ASSESSMENT FORM � ent .. � , e Barr,�t�b'�, h�'.4 Q2�30 / /_4 �' � /�� Address of Inspection: cP Ant# City y 1�,� �1y�/'L�— .� �x�-e � ,�o �o/� C.a � -�— _ 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 � �����SE� ��' � /o�a 3�1� SiG 7 E �ATF