Solano County - Application

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Application

RM Lead Paint Abatement Application - English

I. PROPERTY OWNER/TENANT INFORMATION

* First Name:

Middle Initial

* Last Name:

* Street Number and Name:

Unit/Apt/Bldg Number:

Email Address:

Phone Number:

II. ELIGIBILITY

* Was your home/unit built before 1978?

* Do any children less than 6 years of age live here?

		Yes
		No

If yes, how many children less than 6 years live here?

If no, do children less than 6 years spend 3 hours or more in your home 2 or more days a week at least 60 hours during the year?

		Yes
		No

* Is anyone living in your home pregnant?

		Yes
		No

III. HAZARDOUS CONDITIONS

* Please select all areas where there is damaged, peeling, or chipping paint

		on doors/door frames			on ceilings/walls
		on windows/window frames			on radiator/pipes
		on stairs/floors			on the outside of the home/garage
		on cabinets or shelving