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State of Califomia— Health and Human Services Agency <br />California Department c1 P_.c� - „c,,.. <br />LEAD HAZARD EVALUATION REPORT <br />Section 7 — Date of Lead Hazard Evaluation - <br />Section 2 —Type of Lead Hazard Evaluation (Check one box only) - <br />Lead Inspection ]('sk assessment Clearance Inspection r Other (sped ) _. <br />fY _ <br />Section 3— Structure Where Lead Hazard Evaluation Was Conducted <br />Address (number, street, apartmem (if appliicable )]] -- - - -. - _ <br />C y I County -- - <br />r� h � Zip Coda <br />_'1010 � (� fµ STR rPsC%I.- ,t • F, ' '/ r . <br />Consuuciton date ear / � �k <br />of structure (year) 7YPe of sGucture (check one box only) <br />Multi -unit building School or daycare ..i"le family dwelling <br />1 !l%1V rS ❑ Other (specify)_ <br />Section 4 — Owner of Structure (if business/agency, list contact person) - <br />Name - <br />Address [number,vreet, apanm� t (� applica�)�� <br />I <br />City <br />- -? <br />-State I Zip Ccde / <br />I <br />Section 5 — Results of Lead Hazard Evaluation (check all that apply) <br />- - <br />Ll No lead -based paint detected. <br />f�t _j Lead -based paint detected. <br />J No lead hazards detected. i_7 <br />Lead hazards detected. <br />Section 6— Individual Conducting Lead Hazard Evaluation - - -- -- <br />Name _ <br />Steven Denzler• Telephone number - -- - - -- <br />Address [number, street, apartment (if applicable)] Cit <br />y I State _-rp Cade - <br />605 S. Pacific Avenue, Suite 202 San Pedro <br />CDPH ceniecaa n number CA Y 90731 <br />Name and CDPH certification number of any other individual's Slgnam re ,^ � _ - <br />i <br />1261 , , /7 Date <br />-.a—.p <br />s conduMmg line or test in - , plicable} - -- -- — <br />Section 7 — Attachments <br />A. A <br />lead-based diagram or sketch of the structure indicating the specife locations of each lead hazard cr presence o. <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 numner . <br />first copy and attachments retained by inspector <br />Second copy and attachments retained by Oadner <br />GCPH 8552 t6r0)7 <br />1”" copy Only On attachmentsj mailed cr Taxed rc <br />California Departmert el Public Health <br />Childhood Lead Poisoning Prevention Branch Reports <br />550 Marina Bay Pan<way, Building P, Third Floor <br />Richmond, CA 948046403 <br />1- ax:(510)C20 -5656 <br />19F -131 <br />