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State of Califomia— Health and Human SuMces Agency <br />California Dopartrnrmt or = _ - , «,,.. <br />LEAD HAZARD EVALUATION REPORT <br />Section t — Date of Lead Hazard Evaivatio T, 4 - <br />Section 2 -- Type of Lead Hazard Evaluation (Check one box only) - -- <br />Lead Inspection Risk assessment 'J Clearance Inspector, P 7 other (specify) _ <br />Section 3- Structure Where Lead Hazard Evaluation Was Conducted <br />-"- <br />Address (number, street, apartment (it apphcabic)] <br />TAf ( <br />�tru <br />GI - <br />—_- <br />j Cnunty — <br />Cu ion ate (year) <br />of structure <br />I Type of structure (check ene <br />box Only) <br />- <br />I <br />r <br />S <br />❑ Multi -unit building <br />E] School or daycare <br />��le family cwclling <br />❑ Other isoeelfvl <br />Section 4 — Owner of Structure (if businessiagency, list contact person) <br />Name <br />S/'Wl iephone ncmber <br />Address (number, street, apartment {if <br />City State <br />- -- <br />Zip Code <br />Section 5 — Results of Lead Hazard Evaluation (check all that apply) <br />I <br />_ — <br />No lead -based paint detected. Lead -based paint detecled. <br />1-7 <br />No lead hazards detected. Lj lead ,hazards detected. <br />Section 6 — Individual Conducting Lead Hazard Evaluation - <br />r °'eu'n��e amber <br />Steven Denzler <br />- -- -- - <br />I <br />Address [number, street, apartment iif applicable)] <br />605 S. Pacific Avenue, Suite 202 sate <br />San Pedro <br />_ <br />z`P e - <br />CA <br />CDPH certificafion number _ _ �. <br />Signature <br />90731 <br />i - <br />,f ,, <br />1261 /✓ <br />�; <br />Name <br />Date - -- <br />/ <br />and CDPH certification number of anv other individuals conducting sampling or test: — <br />ng�{�plicable) <br />- <br />Section 7 — Attachments -- <br />.4. A foundation diagram or sketch of the Structure indicating the specifc locations of each lead hazard ch presence of <br />lead -based paint; <br />B. Each testing method, device, and sampling procedure used; <br />C. All data coiiected, including quality control data, laboratory results, including laboratory name, address, and phone nurret�, <br />F"sr ropy and attachments retained by inspector <br />7hlyd copy only (no attachments) mailed or ;axed to <br />Second copy and attachments retained by owner <br />California Department of Public Health <br />Childhood Lead Poisoning Prevention Branch Reports <br />850 Manure Bay Parkway, Building P Third Flour <br />Richmond, CA 94804 -6403 <br />Pax: (510) 620 -5656 <br />t:91`11 8552 (&07) <br />19F -99 <br />