9-Exhibit C-633768 Form Lead Clearance Report Template 09-2022 WEB VERSION.pdf

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Attached to
Environmental Investigation Firms
Solicitation number
550632
Issued by
Wayne County, Detroit City, Michigan

About this file

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This document is a Lead Clearance Report Template form developed by the State of Michigan for use in lead hazard assessment and remediation projects. The template is designed for certified lead inspectors and risk assessors to document visual inspections, dust wipe sampling, and soil contamination testing at residential properties undergoing lead hazard control work. The form captures comprehensive project information including property details, contractor and supervisor credentials, work dates, clearance dates, and laboratory results. It establishes clearance standards for various surfaces, with dust wipe limits of less than 10 micrograms per square foot on floors, 100 micrograms per square foot on window sills and troughs, and 40 micrograms per square foot on exterior porch floors. The template includes sections for documenting the scope of work performed, visual evaluation results for deteriorated paint and debris, dust wipe sampling results with pass/fail determinations, retesting results for samples exceeding clearance levels, and soil sampling results when necessary using Michigan's lead action levels of 1,200 parts per million for general soil and 400 parts per million for child play areas and gardens.

The form requires certification by a Michigan-certified lead inspector or risk assessor and mandates that copies be provided to both the client and property owner. The template emphasizes that lead-contaminated dust represents the most likely exposure pathway for lead poisoning and recommends routine maintenance and cleaning to maintain minimum dust levels. The document serves as a professional guidance tool for environmental investigation firms contracted through the City of Detroit's Office of Contracting and Procurement to conduct environmental services, including lead clearance assessments at multiple Detroit locations under a three-year grant-funded agreement. Contractors must ensure compliance with current Michigan regulations and project-specific funding requirements when completing the clearance reports.

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Lead Clearance Report

VISUAL AND DUST WIPE SAMPLE RESULTS

Clearance report is: TYPE OF CLEARANCE Area/side: FINAL/NOT FINAL

For the property at:

Address City, State ZIP Year Built: Year

Prepared for:

Homeowner Homeowner Name Homeowner Address Homeowner City, State ZIP Phone #: ###- ###- ####

Contractor and supervisor:

Lead Hazard Control Contractor and Supervisor Contractor: Contractor Name Supervisor: Supervisor Name P#: # Contractor Address Contractor City, State ZIP Phone #: ###- ###- ####

Work and clearance dates:

Date of work performed:

Start date: Date End date: Date

Clearance date(s) Interior or exterior Pass or fail Reason for failure (N/A if pass clearance) Clearance date Interior/Exterior Pass/Fail Reason for Failure Clearance date Interior/Exterior Pass/Fail Reason for Failure

Report prepared and submitted by:

Inspector Name Michigan Certification P-0XXXX Date of report: Date

Insert logo here

Company Name Address City, State, Zip Phone number

09/2022 V.1 Page 2 of 8

Contents

Clearance standards for dust wipes

Scope of work and visual evaluation results

Dust wipe clearance sampling and results

Soil clearance sampling and results

Additional information

Laboratory used

Inspector certification

Appendix

Clearance standards for dust wipes

Floors (µg/ft2 = microgram per square foot) Less than 10 µg/ft2

Window sills (µg/ft2) Less than 100 µg/ft2

Window troughs (µg/ft2) Less than 100 µg/ft2

Exterior porch floor (µg/ft2) Less than 40 µg/ft2

Scope of work and visual evaluation results

Table 1: General description of work performed

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

Location Activity

09/2022 V.1 Page 3 of 8

Table 2: Visual evaluation results

Date of visual evaluation: DATE

Work area(s) where visual failed

Deteriorated paint

Debris Visible dust

Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Area Yes/No Yes/No Yes/No Notes

Dust wipe clearance sampling and results

Table 3: Dust wipe clearance results

Date of sampling: DATE

Sample number

Location Surface tested* Lead concentration in µg/ft2

Pass or fail

FB1 Field Blank N/A BRL N/A

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

BRL = Below Reporting Limits; µg/ft2 = microgram per square foot *Surfaces tested: Hard Floor (HF); Carpet Floor (CF); Window Trough (WT); Window Stool/Sill (WS); Exterior Porch

Carpet Floor (EPCF) or Exterior Porch Hard Floor (EPHF)

09/2022 V.1 Page 4 of 8

Table 3.1: Retesting of dust wipe samples above clearance levels results

Date of sampling: DATE

Sample number

Location Surface tested Lead concentration in µg/ft2

Pass or fail

FB1 Field Blank N/A BRL N/A

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

# Location Surface Tested Result Pass/Fail

BRL = Below Reporting Limits; µg/ft2 = microgram per square foot *Surfaces tested: Hard Floor (HF); Carpet Floor (CF); Window Trough (WT); Window Stool/Sill (WS); Exterior Porch

Carpet Floor (EPCF) or Exterior Porch Hard Floor (EPHF)

Soil clearance sampling and results

Table 4: Soil sampling clearance results (if necessary)

Date of sampling: DATE

Sample Number

Location of bare soil area

Play area, non-play area, or garden?

Approx. area in square-feet (ft2)

Lead in soil result in ppm

Pass or fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

# Location Play/non-play/garden ft2 Result Pass/Fail

Michigan lead action levels: Soil – at 1,200 ppm; Child play areas and gardens – at 400 ppm or more. BRL = Below

Reporting Limits; N/D = Not Detected; ppm = parts per million

09/2022 V.1 Page 5 of 8

Additional information

Lead contaminated dust is the most likely exposure pathway for lead poisoning. Areas that failed the clearance examination had lead dust levels exceeding allowable standards. Work site areas represented by failed samples need to be re-cleaned and re-tested until they pass clearance. Routine maintenance and cleaning are strongly recommended to keep dust levels at a minimum.

Comments/recommendations:

Comments/recommendations

Laboratory used

Laboratory Name

Laboratory Address, City, Zip

Phone #: ###- ###- ####

Inspector certification

The information contained in this report is a true and accurate representation of the conditions at this property at the time of lead clearance, based on the professional judgement of the person(s) who conducted and reported this clearance.

Name Date

Michigan Certified Lead Inspector/Risk Assessor # P- 0XXXX

Risk Assessor E-Mail: email address

Notice to professionals:

Copies of this report must be provided to the client requesting the clearance and the property owner if they are different individuals.

Professional templates are intended to be used as a guidance tool. The individual completing this form is responsible for ensuring all rules and regulations are followed. Information contained within these templates should be reviewed by the professional routinely to ensure the content meets current regulations and any specific project funding requirements.

09/2022 V.1 Page 6 of 8

Appendix

APPENDIX A – PHOTOS

Caption Caption

Caption

09/2022 V.1 Page 7 of 8

09/2022 V.1 Page 8 of 8

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