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l 4 <br /> CLEARANCE INSPECTION—oummary Statement <br /> Address sampled Date of referral <br /> S8 S, Ay;et"OXF wY, a 126 /o <br /> Cily/County/Zip Date of environmental investigation <br /> 5'�rk70nrlS/>'� SaRt2uTau /95202- 03 i� <br /> Phone Estimated year built Date of summary statement <br /> 1906 ail zr 161 <br /> Case Local 10: Environmental professronaf name <br /> {k nxxmw Soap <br /> htedi-Cal# I/A r Expiration c'ate <br /> S-ro6rr 071 16 / 1,,5 <br /> Persons present during clearance inspection Clearance dale Time arrived at adc =_ss 4 R :L,S/hq <br /> �kePLRr9 (�H/nJste 06126 169 Trre departed ass /l :57,s�4 <br /> Subrnir, d by: 2�REHS ❑ Private consultant <br /> CIH ❑ Oiher En-rironn_ntai Prct=ssional <br /> Date of DHS Form 6552 subnirai: 0-717-3 /01 <br /> 1.VISUAL INSPECTION <br /> Exterior <br /> ® Exterior lead hazard work completed <br /> Interior <br /> ® Inle6or lead hazard work completed <br /> 2.NUMBER OF ENVIRONMENTAL SAMPLES <br /> XRF Lab <br /> Soil Dusl Soil(AA) Dust(AA) TOTAL <br /> Total a of samples taken d 0 <br /> Ir above regulatory standard <br /> D � d � D <br /> 3.CLEARANCE BY PRIVATE CONSULTANT <br /> Phone <br /> o Address <br /> a.S, <br /> OHS Inspector/Assessor p e r r <br /> I <br /> 4.ON-SITE RECOMMENDATIONS TO CHILD'S PARENT/GUARDIAN TO MAINTAIN LEAD-SAFE PROPERTY <br /> SLY <br /> M6" ID O.:F RPIf II O"94,, <br /> 5.DATE OF NOTIFICATION TO LANDLORDIPROPERTY OWNER OF CLEARANCE 08-1 z( I01 <br /> 3/74 Lead Poisoning Follow-up Form California Department of Health Services Childhood Lead Poisoning Prevenlion Branch Appendix 6 <br />