Confirmation of Receipt of Lead Pamphlet
I have received a copy of the pamphlet, Protect Your Family From Lead in Your Home , informing me of the potential risk of the lead hazard exposure from renovation
Activity, to be performed in my dwelling unit I received this pamphlet before the work began.
________________________________ ____________________________________
Printed name of recipient:____
Date
Signature of recipient:____
Date
If the lead pamphlet was delivered but a tenant signature was not obtainable, check the appropriate box below.
______ Refusal to sign
______I certify that I have made a good faith effort to deliver:
Protect your Family From Lead In Your Home, to the rental
dwelling unit listed below at the date and time indicated and that the
occupant refused to sign the confirmation of receipt. I further certify
that I have left a copy of the pamphlet at the unit with the occupant.
_______ Unavailable for signature
_______I certify that I have made a good faith effort to deliver the
pamphlet, Protect Your Family From Lead In Your Home, to the rental
dwelling unit listed below and that the occupant was unavailable. I have left a
copy of the pamphlet at the unit by sliding it under the door.
Printed name of person certifying:___
Attempted delivery date and time of lead pamphlet_____________ _______________
Signature of person certifying lead pamphlet delivery:___
Unit Address:
* You may delivery in person or mail the lead pamphlet.
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