If you would like to request a
Free In-Home Lead Consultation
, please complete the form below and press submit. This service is available free to owners of pre-1978 residential property in Alameda, Berkeley, Emeryville and Oakland.
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Indicates required field
General Information
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Owner Name(s):
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Property Address:
City:
Zip:
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Owner's Mailing Address:
City:
State:
Zip:
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Contact Name:
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Daytime Phone Number(s):
E-Mail Address:
Property Information
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Occupancy (Check one) :
Owner Occupied
Rental
Owner occupied and rental units
Vacant
Total number of units:
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Which units do you want us to visit?
Specify unit(s) #'s:
Reason for Request
(check all that apply)
Peeling Paint on:
exterior
interior
Children under 6 in home. Indicate age(s):
Renovations planned. Approximate start date:
minor repairs
one room remodel
extensive repainting
major remodel
addition
Will you be disturbing any painted surfaces?
Yes
No
Other/Notes:
Rental Property
If you have rental units on this parcel, please let us know if you would like us to contact and schedule the appointment with your tenant. We recommend that the property owner be present during the site visit but it is not required. We will provide the tenant and the property owner with a copy of the visual survey report. Please check the applicable box(es) below:
Schedule the appointment with my tenant and notify me of the date
Contact me directly and I will notify my tenant
Unit #
Tenant Name
Tenant Phone Number
# of Children under 6
If you need to enter more tenants, please enter the number of additional tenants to list and click 'Add Tenants'
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AUTHORIZATION
I hereby certify that I am the legal owner or the owners authorized representative of the property listed above and to the best of my knowledge, all statements and representations made in this document are true and complete. I am requesting an in-home lead consultation from the Alameda County Lead Poisoning Prevention Program including a visit to my property to conduct a visual survey and to provide consultation services.