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. i ? <br /> State of California—health and Human Services Agency <br /> California Department of Public Health <br /> LEAD HAZARD EVALUATION REPORT <br /> Section 1 —Date of Lead Hazard Evaluation 03 30/oq <br /> Section 2—Type of Lead Hazard Evaluation(Check one box only) <br /> ❑ Lead Inspection ❑ Risk assessment ❑ Clearance Inspection � Other(specify) �v✓ N1wfNA4L --rNVy � <br /> Section 3—Structure Where Lead Hazard Evaluation Was Conducted <br /> Address[number,street,apartment(if applicable)) City County Tip Code <br /> 38 soi4w 4TRPoRT w ejTekinnf SAj✓S�uSnr 9S24b <br /> Construction date(year) Type of structure(check one box only) <br /> of structure <br /> ❑ <br /> 1988 Multi-unit building ❑ School or daycare Single family dwelling <br /> ❑ Other(specify) <br /> Section 4—Owner of Structure(if business/agency, list contact person) <br /> !Name <br /> Telephone number <br /> K SMG P L7-w R <br /> Address[number,street,apartment(if applicable)] City State Zip Code <br /> 3935 f 4S7 O st �T S�vck'r7�n! G9G1FaRN2i9 95 2/S <br /> Section 5—Results of Lead Hazard Evaluation(check all that apply) <br /> ❑ No lead-based paint detected. � Lead-based paint detected. <br /> ❑ No lead hazards detected. ® Lead hazards detected. <br /> Section 6—Individual Conducting Lead Hazard Evaluation <br /> Name Telephone number <br /> amlflN Saav Zo9 WS-99Cs <br /> Address[number,street,apartment(if applicable)) City State Zip Code <br /> boo ; y�T S?tacy7nN GA�1GdRN1�1 '?SW 2- <br /> CDPH certification number Signature Date <br /> 1-10411 4,... o tf/4Y/o 4 <br /> Name and CDPH certification number of any other individuals conducting sampling or testing(if applicable) <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 /> B. 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 /> 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 /> coPH 8552(s07) <br />