IOWA LEAD-SAFE RENOVATION REPORT

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1 IOWA LEAD-SAFE RENOVATION REPORT A. Date report issued: / / B. Important information. Please be aware that as of April 22, 2010 renovations* that take place in pre-1978 residential housing and child occupied facilities are regulated and certification is required. This renovation report is required to be completed within 30-days following a renovation. This report is required to be kept for 3 years by the Iowa certified firm and certified individual conducting the renovation. This renovation report is always required to be issued to the property owner(s) of the address where the renovation occurred. This report may also be required to go to other parties if the renovation occurred in a unit that is not owner occupied, or in a child occupied facility. Check all that apply. An adult occupant of a renovated unit, that is not owner occupied. Name(s): The person who requested the renovation, if different from the property owner or adult occupant. Name(s): The adult representative of a child occupied facility. Name(s): Renovations in a child occupied facility or in the common area(s) of multifamily housing. A notice that is likely to be seen shall be posted. The notice shall include instructions on how the report can be obtained free of charge. *Simply stated, renovation is the modification of any existing structure, or portion thereof that results in the disturbance of painted surfaces. C. Address renovated. Street:, IA Zip: Apartment numbers (if applicable): Year built: Property owner(s) name: Owner telephone: Property owner address: Street: State: Zip: D. Certification information. Name of certified firm: Firm certification number: IA FIRM Firm telephone:

2 Name of certified individual assigned to renovation: Individual certification number: IA Telephone: Individuals must be certified as a Lead-Safe Renovator, a Lead Abatement Contractor, or a Lead Abatement Worker to do renovation. E. Renovation information. Date(s): renovation occurred: Brief description of renovation work: F. Exemptions. Specific work practices related to lead-based paint are required. Some or all of the work practices may be exempt. Check any applicable exemption below: The entire property was determined to be free of lead-based paint by an Iowa certified lead inspector/risk assessor. (Attach report or executive summary of report) All work practices are exempt if property if free of lead-based paint. The renovations were considered to be emergency in nature**. Emergency renovations are exempt from the work practices. However, post-renovation cleaning verification or clearance testing by an Iowa certified lead professional is still required. (Attach documentation of emergency) Some or all of the surfaces renovated were negative for lead-based paint when tested with an EPA approved test kit(s). Only Iowa certified lead-safe renovators, lead abatement contractors, and lead abatement workers can use EPA approved test kits. All of the results, positive and negative must be reported. (See see section H) Some or all of the surfaces renovated were negative for lead-based paint when tested by an Iowa certified lead inspector/risk assessor using XRF or laboratory analysis. Only Iowa certified lead inspector risk/assessors can test paint using XRF or laboratory analysis. (Attach inspection report) **Emergency renovation are non-routine failures of equipment or of a structure that were not planned but resulted from a sudden, unexpected event that, if not immediately attended to, presents a safety or public health hazard or threatens equipment or property with significant damage. Renovations conducted in response to an elevated blood lead (EBL) inspection are also considered to be emergency.

3 G. Work practices. Specific work practices are required for renovation. Some or all of the work practices may be exempt, see section F. Check all of the work practices that apply and describe if necessary. The description of the work practice must be location specific. All Warning signs posted. Location(s): Work area contained. Type of containment: Interior All objects in work area covered. All object in work are removed. HVAC ducts closed and covered. Floors in and near the work area covered. All windows and doors in the works area closed. Containment for doors used as entrance to work areas. Exterior All windows in the work area and within 20 feet of work area closed. All doors in the work areas and within 20 feet of work area closed. Ground covered to contain all dust and debris. Vertical containment. Multistory Exterior All windows and doors below the renovation closed.

4 Waste Storage All waste from renovation stored under containment. Waste Transportation All waste from renovation transported under containment. Additional/Other Work Practices H. EPA approved test kit information. If test kits were used to determine the presence or absence of lead-based paint then all of the results must be included in this report. Use the Lead test kit documentation form and attach it to this renovation report, if applicable. Lead test kit documentation form is attached. Not applicable. No EPA approved test kits used. I. Training information and documentation. Every individual that performs renovation work is required to be trained in lead safe work practices. A training course is not required for all individuals performing the renovation. For individuals that are not certified the required training must occur on-the-job. All on-the-job training must be documented. Use the Training documentation form and attach it to this renovation report, if applicable. Training documentation form is attached. Not applicable. The certified individual listed in section D of this report was the only renovator. J. Post-renovation cleaning verification or clearance testing. Each renovation must conclude with post-renovation cleaning verification or clearance testing. Only Iowa certified lead-safe renovators, lead abatement contractors, or lead abatement worker can perform the postrenovation cleaning verification. Only Iowa certified sampling technicians or lead inspector/risk assessors can perform clearance testing. Check one. Clearance testing. The clearance report from the certified sampling technician or lead inspector/risk assessor must be attached to this renovation report. Post-renovation cleaning verification. The post-renovation cleaning verification documentation form is

5 attached. K. Other applicable laws. Federal law requires that any known information about lead-based paint be disclosed when residential properties built before 1978 are sold or leased. Known information would include results from recognized testing kits. If a recognized test kits was used during this renovation then the property owner will need to disclose this renovation report. In addition to any known information the brochure, Lead Poisoning: How to Protect Iowa Families is required to be given out. The U.S. Environmental Protection Agency (EPA) and the Department of Housing and Urban Development (HUD) both enforce the disclosure rule. Iowa law requires a notification prior to renovations that take place in residential property or child occupied facilities built prior to The brochure, Lead Poisoning: How to Protect Iowa Families is also needed for compliance with these rules. Check to indicate that the notification and brochure were given prior to this renovation. L. Signature of Iowa certified individual listed in section D of this report: Date:

6 LEAD TEST KIT DOCUMENTATION FORM This form must be attached to the Iowa Lead-Safe Renovation Report. Page 1 of Street address: Apt:, IA Zip: TEST 1 Lot #: Test location ( Example, NW bedroom 2 nd floor north window sill) TEST 2 same as previous? Yes (skip section) No (complete section) Lot #: Test location TEST 3 same as previous? Yes (skip section) No (complete section) Lot #: Test location

7 TEST KIT DOCUMENTATION FORM Page of TEST # same as previous? Yes (skip section) No (complete section) Lot #: Test location TEST # same as previous? Yes (skip section) No (complete section) Lot #: Test location TEST # same as previous? Yes (skip section) No (complete section) Lot #: Test location

8 TRAINING DOCUMENTATION FORM This form must be attached to the Iowa Lead-Safe Renovation Report. Page 1 of Street address: Apt:, IA Zip: Each individual that worked on the renovation jobsite must be listed below*. Each individual must have documented training in lead safe work practices. Listed below are three options to document the required training. Use at least one of these options for each individual listed in the table below. 1. The individual is certified to do renovations in Iowa. You must list the certification number. 2. The individual has previously received on-the-job training from this firm**. Previous on-the-job training must cover each type of work performed on this job. 3. The individual is currently receiving on-the-job training. This option must include a description of the onthe-job training. If necessary use the blank lines below this table to further describe the on-the-job training. First Name Last Name Option(s) Certification number or Description of training. Example John 1. Smith 2 and 3 Proper exterior worksite containment was discussed and demonstrated *The certified individual that completes and signs the Iowa Lead-Safe Renovation Report does not need to be listed. ** Firms shall not recognize on-the-job training from other firms.

9 TRAINING DOCUMENTATION FORM Page of First Name Last Name Option(s) Certification number or Description of training.

10 POST-RENOVATION CLEANING VERIFCATION DOCUMENTATION FORM This form must be attached to the Iowa Lead-Safe Renovation Report. Page 1 of Street address: Apt:, IA Zip: 1. The first step in the post-renovation cleaning verification is a visual inspection to determine if all of the dust, debris, and residue in the work area was been removed. Do not proceed to step two of the post-renovation cleaning verification until the work areas is free of dust, debris, and residue. Visual inspection passed (check when complete). 2. The second step of the post-renovation cleaning verification is to verify that the work area has been cleaned. This verification process is a series of wipes taken on window sills, window troughs, uncarpeted floors, and countertops and then compared to a cleaning verification card. Each window sill, window trough, uncarpeted floor, or countertop in the work area must be wiped and verified as clean. If a component fails the first or second wipe test then it must be recleaned before the next wipe test. A component that is recleaned following a failed second wipe test must be allowed to dry for at least one hour before the third wipe with the dry electrostatically charged dry cloth. The component is considered clean when it passes the first or second wipe test, or after the 3 rd wipe with an electrostatically charged dry cleaning cloth. Each wipe can be used on up to 40 square feet of uncarpeted floor or countertop. Date of post-renovations cleaning verification: / /. Expiration date of cleaning verification card: / /. WS = window sill WT = window trough UF = uncarpeted floor C = countertop P = pass F = fail N = north S = south E = east W = west Circle all that apply in the table below. Room Component Component Wipe result 1 Wipe result 2 Wipe result 3 Location Wet disposable Wet disposable Dry electrostatic Example Dining Room Middle of 3 P F P F P

11 POST-RENOVATION CLEANING VERIFCATION DOCUMENTATION FORM Page of WS = window sill WT = window trough UF = uncarpeted floor C = countertop P = pass F = fail N = north S = south E = east W = west Circle all that apply in the table below. Room Component Component Wipe result 1 Wipe result 2 Wipe result 3 Location Wet disposable Wet disposable Dry electrostatic WS WT UF C WS WT UF C WS WT UF C

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