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State of California—Health and Human Services Agency California Department of Public Health <br /> LEAD HAZARD EVALUATION REPORT <br /> Section 1 — Date of Lead Hazard Evaluation 06/27/09 <br /> Section 2 -- Type of Lead Hazard Evaluation(Check one box only) <br /> ❑ Lead Inspection ❑ Risk assessment ❑✓ Clearance Inspection ❑ Other(specify) <br /> Section 3 — Structure Where Lead Hazard Evaluation Was Conducted <br /> Address[number,street,apartment(if applicable)] City County Zip Code <br /> 38 SOUTH AIRPORT WAY STOCKTON SAN JOAQUIN 95206 <br /> Construction date(year) Type of structure Children living in structure? <br /> of structure <br /> ❑ Multi-unit building ❑ School or daycare 0 Yes ❑ No <br /> 1900 ❑ Single family dwelling ❑ Other ❑ Don't Know <br /> Section 4 — Owner of Structure(if business/agency, list contact person) <br /> Name Telephone number <br /> i <br /> KING, PETER R. & ILA M. <br /> Address[number,street,apartment(if applicable)] City State Zip Code <br /> 3835 EAST MAIN STREET STOCKTONCALIFORNIA. 95215 <br /> Section 5 — Results of Lead Hazard Evaluation(check all that apply) <br /> ❑ No lead-based paint detected ❑ Intact lead-based paint detected ❑ Deteriorated lead-based paint detected <br /> ❑ No lead hazards detected Lead-contaminated dust found k <br /> ❑ ❑ Lead-contaminated soil found ❑ Other <br /> Section 6 — Individual Conducting Lead hazard Evaluation II <br /> Name Telephone number <br /> OMRAN SOOD (209) 468-9965 <br /> Address[number,street,apartment(if applicable)] City State Zip Code <br /> 600 EAST MAIN STREET STOCKTON CALIFORNIA 95202 <br /> CDPH certification number Signature Dale , <br /> I-10611 <br /> Name and CDPH certification number of any other individuals conducting sampling or testing(if applicable) <br /> NIA <br /> Section 7 — Attachments <br /> A.A foundation diagram or sketch of the structure indicating the specifc locations of each lead hazard or presence of <br /> lead-based paint; <br /> 8. Each testing method, device, and sampling procedure used; <br /> C.All data collected, including quality control data, laboratory results,including laboratory name, address, and phone number. <br /> I <br /> First copy and attachments retained by inspector Third copy only(no attachments)mailed or faxed to: <br /> Second copy and attachments retained by owner California Department of Public Health <br /> Childhood Lead Poisoning Prevention Branch Reports <br /> 850 Marina Bay Parkway,Building P,Third Floor <br /> Richmond,CA 94804-6403 <br /> Fax:(510)620-5656 <br /> CDPH 855216/071 <br />