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TRANSMISSION VERIFICATION REPORT <br /> TIME : 04/1412009 13: 29 <br /> NAME : SJC ENV HEALTH DEPT <br /> FAX : 2094688392 <br /> TEL - <br /> SER.# BROM7J748813 <br /> DATE,TIME 04/14 13:29 <br /> FAX NO./NAME 915106205656 <br /> DURATION 00: 00:16 <br /> PAGE(S) 01 <br /> RESULT OK <br /> MODE STANDARD <br /> ECM <br /> State of Catirornia—Health and Human Services Agency Callfernia Department of Public Hcalth <br /> LEAD HAZARD EVALUATION REPORT <br /> Section i —mate of Lead Hazard Evaluation 6S/3 n/a j <br /> Section 2—Type of Lead Hazard Evaluation (Check one box only) <br /> ❑ Lead Inspection ❑ Risk assessment ❑ cioaranoa Inspection S.Other(specify) &MVNI z- .7Nvis%� <br /> Section 3---Structure Where Lead Hazard Evatuation Was Conducted <br /> Address[number,street,apartment(If applicable)] City County Zip Gado <br /> 7DGkr�N SW�RgN� rlS?06 <br /> 32 .Sd�� A�iPPcR- w _ <br /> Construction date(year) Type of structure(cheek one box only)V <br /> of structure <br /> ❑ Multi-unit bullang School or daycare JR Single familydweking <br /> 19D ❑ other(specify), - <br /> Section d-T Owner of Structure(If businesslagency,list contact person) <br /> Name^ — Telephone number - <br /> Address[number,street,apartment(if applicable)] City State Zip Code <br /> 3935 �OJSi /NjfLW STWZ7- 5711u// /] <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 m Telephon6 number w <br /> Saco _ 2v4 <br /> AddraSs[number,street,apartment(If applioatlla)J City State Zip Code <br /> 600 %&r' r9A ._S >`T 511X^1 P1 _ aIi7_�dXIVIT 4 9S2O2 <br /> CDPH certification number Signature bate <br />