J-0200000-05 Maryland Lead Form B_Visual Inspection.pdf

MARYLAND DEPARTMENT OF THE ENVIRONMENT

Land Management Administration • Lead Poisoning Prevention Compliance & Accreditation Division

1800 Washington Blvd. • Suite 630 • Baltimore Maryland 21230

(410) 537-3825 • 1-800-633-6101 x3825 • www.mde.state.md.us

Form Number: MDE/LMA/CER.034 Page 1 of 2 Revision Date 10/2011 TTY Users 1-800-735-2258 Recycled Paper

FORM B – VISUAL INSPECTION (For Modified Risk Reduction)

Effective January 1, 2012 Forms B & C must be submitted with the Inspection Certificate (Form

330) for meeting the Modified Risk Reduction Standard. The lead inspector is to submit a copy of the Form 330, a Form B with original signed Supervisor’s Statement of Work, and Form C with diagram and laboratory results, to Maryland Department of the Environment WITHIN 10 CALENDAR DAYS following receipt of the laboratory analysis report. (COMAR 26.16.02.03). This form must be fully completed and accurate or the Inspection Certificate may be invalidated. (EA 6-8, COMAR 26.16.02.03 and COMAR 26.16.05.05).

MDE Tracking No.: Date of Inspection: MM/DD/20YY

Inspection Certificate No.:

Address of Property Inspected:

Street Address:

Unit No.: City: Zip Code:

In accordance with COMAR 26.16.02.03, certification of a Visual Inspection shall not be issued with out a statement, Supervisor’s Statement of Work (SSW), signed by an accredited supervisor stating that all the lead hazard reduction statement were performed, or are still in effect, in accordance with the statute and applicable regulations. The Supervisor’s Statement of Work (SSW), with original signature, is to be attached to this form.

Supervisor’s Accreditation No.: ____________ Accreditation Expiration Date: _____/_____/________

Supervisor’s Name: ___________________________________________________________________

Date of Supervisor’s Statement of Work: (mm/dd/20yy) _____/_____/_________

PART II

Enter the total number of each component type within the unit/property.

WINDOWS TOTAL

NUMBER WINDOW SILLS TOTAL

NUMBER

Lead Free / Replacement Repainted Non Lead Free Replaced Upper Sash Fixed Enclosed / Wrapped Windows with lead free friction surfaces Encapsulated (MDE approved material)

Casement WINDOW WELLS Other Capped (as applicable)

FORM B, PART III- Modified Risk Reduction Treatments Confirm the following treatments have been completed satisfactorily, pursuant to COMAR 26.16.05 and Environmental Article 6-8.

Satisfactory?

(circle one in each row)

All interior and exterior surfaces are free of chipping, peeling or flaking paint. Yes / No

The Dwelling unit is free of structural defects that could cause paint to chip, peel or flake. Yes / No

All interior window sills where lead based paint or untested paint exists have been repainted, replaced or encapsulated. (Attach XRF results for tested sills.) Yes / No

All untested window wells where lead based paint or untested paint exists are capped, with vinyl, aluminum, or other MDE approved material, in order to make them smooth and cleanable.

Yes / No

Top sash of untreated or non-replacement windows have been fixed to eliminate friction. (Subject to Federal, State and Local Codes.) Yes / No

Doors have been re-hung to prevent the rubbing together of a lead-painted surface with another surface. Yes / No

All kitchen and bathroom floors are overlaid with smooth, water resistant covering. Yes / No

The unit is free of visible dust, debris or residue.

HEPA-vacuuming and detergent washing have been done in rooms where repairs were made.

Yes / No

Comments:

Accredited Inspection Contractor’s Name:

(print)

Accreditation No.: Accreditation Expiration Date:

Accredited Inspector’s Name: (print)

Accreditation No.: Accreditation Expiration Date:

Accredited inspector’s Signature: Date: (MM / DD / 20YY)

Form Number: MDE/LMA/CER.034 Page 2 of 2 Revision Date 10/2011 TTY Users 1-800-735-2258 Recycled Paper

FORM B – VISUAL INSPECTION (For Modified Risk Reduction)