Michigan PDF Forms

Michigan PDF Forms
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Documents used along the form

The Michigan DCH 0654 form is a notification document required for lead abatement activities within the state. Several other forms and documents complement this form, ensuring compliance with state regulations and facilitating effective communication among involved parties. Below is a list of related documents that are often used alongside the DCH 0654 form.

  • Lead Abatement Contractor License: This document verifies that the contractor performing the lead abatement has the necessary licenses and certifications to conduct such work in Michigan. It ensures that the contractor is qualified and adheres to state regulations.
  • Lead Risk Assessment Report: A detailed report that assesses the presence and risk of lead-based paint in a property. This document is crucial for understanding the extent of lead hazards and informing the abatement process.
  • Notice of Intent to Abate: This form is submitted to inform relevant authorities about the planned lead abatement activities. It typically includes details about the project scope and timeline, similar to the DCH 0654 form.
  • Post-Abatement Clearance Report: After the completion of lead abatement, this report confirms that the area has been tested and is safe for reoccupation. It provides documentation that the abatement was conducted properly and meets safety standards.
  • Work Plan for Lead Abatement: This document outlines the specific procedures and methods that will be used during the lead abatement process. It serves as a guide for contractors and ensures that all safety protocols are followed.
  • Release of Liability Form: For activities involving potential risks, it is important to have a detailed Release of Liability form guideline to outline responsibilities and protect against unforeseen events.
  • Occupant Notification Letter: This letter is sent to inform residents or occupants of the property about the lead abatement activities. It includes information about potential risks and safety measures taken during the process.

These documents play a vital role in the lead abatement process, ensuring compliance with state laws and protecting the health and safety of the community. Proper documentation helps streamline communication and maintain transparency among all parties involved in lead abatement activities.

Michigan Dch 0654 Preview

MAIL OR FAX TO:
MDCH - Healthy Homes Section
P.O. Box 30195
Lansing, MI 48909
Attn: Compliance Officer
FAX: 517-335-8800

Notification of Lead Abatement Activity

Any [firm] conducting lead-based paint [abatement] activities in the state of Michigan must notify the department of that activity not less than three (3) business days prior to its commencement, as required by §333.5472 of the Michigan Lead Abatement Act of 1998, as amended.

All information is required. Incomplete notifications will not be approved.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notification Date:

 

 

Start Date:

 

 

End Date:

 

 

 

Revision #: (for

 

 

 

 

 

 

 

 

 

changes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for revision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Scheduled work hours:_______________ to_______________

⃝

Weekends included

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contractor Name:

 

 

 

 

 

 

 

 

 

MI Certification #:

C- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certified Lead Abatement

 

 

 

 

 

 

 

 

MI Certification #:

 

 

 

Supervisor for this project:

 

 

 

 

 

 

 

 

P- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Risk Assessor:

 

 

 

 

 

 

 

 

 

MI Certification #:

P- ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of lead-based paint assessment:

 

⃝ Risk assessment

 

⃝ Inspection

 

⃝ Assumed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Building Owner:

 

 

 

 

 

 

Owner phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Project/Site

 

 

 

 

 

 

City:

 

 

 

 

 

 

Zip:

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment numbers:

 

 

 

 

 

 

 

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupancy Status

 

 

Building Type

 

 

 

 

Occupancy Type

⃝ Occupied:

⃝ Vacant:

 

⃝ Single-family

 

 

 

 

⃝ Rental

(includes temporary

(abandoned/unoccupied)

 

⃝ Multi-family

 

 

 

 

⃝ Owner Occupied

relocation)

 

 

 

 

⃝ Child occupied facility

 

 

⃝ Vacant or unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Housing Agency: (agency funding the project)

Contact Person:

Phone #:

Scope of Work

⃝ Interior ⃝ Exterior

⃝ Encapsulation ⃝ Enclosure ⃝ Component removal ⃝ Paint removal ⃝ Soil

Brief detail of scope of work (replace windows, exterior doors, interior doors, siding, encapsulate baseboards room #4, etc)

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

1. Complete form.

2. Return to HHS at least three (3) business days prior to the commencement of abatement work.

3. If project schedule changes, mark the appropriate revision number at the top of the form and send in at least 24 hours prior to change.

DCH-0654 Revised (06/12)

Similar forms

  • Lead Abatement Notification Form (LANS): Similar to the DCH 0654 form, this document serves to inform relevant authorities about upcoming lead abatement activities. It requires detailed project information, including contractor details and project timelines.
  • Environmental Protection Agency (EPA) Lead Renovation, Repair and Painting (RRP) Notification Form: This form is used by contractors to notify the EPA about lead-based paint activities. Like the DCH 0654, it emphasizes the importance of notifying authorities before work begins.
  • California Vehicle Purchase Agreement Form - This form is essential for ensuring transparency in vehicle transactions in California and shares similarities in purpose with the DCH 0654, as both provide critical contractual information and establish clear communication of rights and obligations in their respective processes. For more details, visit Formaid Org.
  • State of Michigan Lead Inspection Report: This report provides the results of lead inspections conducted on properties. It shares similarities with the DCH 0654 in that it documents lead-related activities and findings, requiring detailed information about the property and inspection results.
  • Lead Risk Assessment Report: This document assesses the risk of lead exposure in a property. Similar to the DCH 0654, it requires comprehensive details about the property, the assessment process, and findings, ensuring that all parties are informed about potential hazards.
  • Notification of Lead Hazard Reduction Activities: This notification is required when lead hazard reduction activities are planned. It parallels the DCH 0654 form by mandating advance notice to authorities and providing essential project details.
  • Lead-Based Paint Disclosure Form: This form is used in real estate transactions to inform buyers and renters about the presence of lead-based paint. Like the DCH 0654, it aims to ensure that individuals are aware of lead risks and the necessary precautions.

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Misconceptions

Misconceptions about the Michigan DCH 0654 form can lead to confusion and potential delays in lead abatement activities. Here are eight common misconceptions:

  • Only large companies need to file the form. Any firm, regardless of size, conducting lead-based paint activities must submit this notification.
  • Submitting the form is optional. It is mandatory to notify the department at least three business days before starting any abatement work.
  • Incomplete forms can be accepted. All information is required. Incomplete notifications will not be approved, which can delay your project.
  • The form can be submitted after work has begun. You must submit the form before starting any lead abatement activities, not after.
  • Only one notification is needed for multiple projects. Each project requires a separate notification. Do not combine multiple projects into one submission.
  • Changes to the project schedule don’t need to be reported. If there are changes, you must mark the revision number and submit the updated form at least 24 hours before the change.
  • The form can be faxed or mailed at any time. Ensure you send it at least three business days prior to the start date to avoid penalties.
  • Any contact person can be listed. The contact person must be someone involved in the project, ensuring effective communication with the department.

Understanding these misconceptions is crucial for compliance and the successful execution of lead abatement activities in Michigan.

Detailed Instructions for Using Michigan Dch 0654

Filling out the Michigan DCH 0654 form is an important step if you are conducting lead-based paint abatement activities in the state. It ensures that the necessary authorities are informed ahead of time. Follow these steps carefully to complete the form accurately.

  1. Begin by entering the Notification Date at the top of the form.
  2. Fill in the Start Date and End Date for the abatement work.
  3. If there are any changes to a previously submitted form, indicate the Revision #.
  4. Specify the Reason for revision if applicable.
  5. List the Scheduled work hours, including start and end times.
  6. Enter the Contractor Name and their MI Certification #.
  7. Provide the Contact Person and their Phone #.
  8. Fill in the Certified Lead Abatement Supervisor's MI Certification #.
  9. Include the Risk Assessor's MI Certification #.
  10. Check the appropriate box for the Type of lead-based paint assessment (Risk assessment, Inspection, or Assumed).
  11. Enter the Building Owner and their Owner phone #.
  12. Provide the Project/Site City, Zip, and Address.
  13. If applicable, include Apt numbers and County.
  14. Indicate the Occupancy Status and Building Type by checking the appropriate boxes.
  15. Fill in the Housing Agency funding the project and the Contact Person with their Phone #.
  16. Specify the Scope of Work by checking the relevant boxes.
  17. Provide a brief detail of the scope of work in the space provided.

Once you have completed the form, make sure to return it to the Healthy Homes Section at least three business days before starting the abatement work. If your project schedule changes, remember to indicate the revision number at the top and submit it at least 24 hours before the change occurs.

Dos and Don'ts

When filling out the Michigan DCH 0654 form, it is important to follow certain guidelines to ensure compliance and efficiency. Here are six things you should and shouldn't do:

  • Do complete the form in full. Every section must be filled out to avoid delays.
  • Do submit the form at least three business days before starting any lead abatement work.
  • Do provide accurate contact information for all parties involved in the project.
  • Do indicate any changes to the project schedule by marking the revision number and submitting the updated form.
  • Don't leave any sections blank. Incomplete forms will not be approved.
  • Don't submit the form after the deadline. Late submissions can lead to penalties or project delays.