Provided courtesy of Tri-Tech Building Hygiene Services, Oak Park, MI

Renovation Notice of Potential Lead-Based Paint Related Work

Notification and Disclosure Acknowledgement

Beginning April 22, 2010, federal law requires that personnel performing renovation,

repair and painting projects that disturb more than six square feet of paint in rental

homes, child care facilities, schools and other child-occupied facilities built before 1978

must be certified and trained to follow specific work practices to prevent lead

contamination. Renovators must provide a copy of the “Renovate Right” pamphlet to

occupants of child-occupied facilities when 2 square feet or more of known or assumed

lead paint is potentially disturbed.

Pamphlet Receipt

I have received a copy of the pamphlet, “Renovate Right”, informing me of the potential

risk of lead hazard exposure from renovation activity to be performed in my dwelling

unit. I received this pamphlet before the work began. I have the right to additional lead

paint information, if available, from the owner. If I am the owner, I have made good faith

efforts to disclose knowledge or record of lead-based paint that may be present to the

contractor.

_________________________________

Printed Name and Signature

_____________________________

Date

______________________________

Building Address

Note: If an occupant is unavailable for signature or refuses to sign the acknowledgement

of receipt of the pamphlet, then the renovator may self-certify notification compliance:

I certify that I have made a good faith effort to deliver the pamphlet to the person listed

below at the dates and times indicated, and that the occupant refused to sign or was

unavailable to sign the acknowledgement. I further certify that I have left a copy of the

pamphlet at/with____________________________________.

______________________________

Printed Name and Signature

Attempted delivery dates and times:________________________________________

Note: A copy of this record should be maintained by both the owner and the renovator (if different)