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Free Michigan Dch 0654 Template in PDF

The Michigan DCH 0654 form serves as a crucial notification document for any firm engaging in lead-based paint abatement activities within the state. This form must be submitted to the Michigan Department of Community Health at least three business days before the start of any abatement work, ensuring compliance with state regulations. By providing essential information about the project, the form helps maintain safety standards and protects public health.

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The Michigan DCH 0654 form plays a crucial role in ensuring safe lead abatement practices throughout the state. This form must be submitted by any firm planning to conduct lead-based paint abatement activities, providing necessary notifications to the Michigan Department of Community Health. Before beginning work, contractors are required to notify the department at least three business days in advance, as mandated by the Michigan Lead Abatement Act of 1998. This notification process is designed to protect public health and ensure compliance with state regulations. The form collects vital information, including the project’s start and end dates, contractor details, and a description of the scope of work. It also requires specifics about the building type and occupancy status, ensuring that all relevant factors are considered before the abatement begins. If there are any changes to the project schedule, the form allows for easy revisions, provided they are communicated promptly. Completing the DCH 0654 accurately and submitting it on time is essential for any firm engaged in lead abatement, as incomplete submissions will not be approved, which could delay critical safety measures.

Form Example

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)

▼ Michigan Dch 0654 PDF Form

Document Specs

Fact Name	Description
Purpose	The Michigan DCH 0654 form is used to notify the state about lead abatement activities being conducted.
Notification Requirement	Any firm conducting lead-based paint activities must notify the Michigan Department of Community Health at least three business days before starting work.
Governing Law	This form is governed by §333.5472 of the Michigan Lead Abatement Act of 1998, as amended.
Incomplete Submissions	Notifications that are incomplete will not be approved, emphasizing the importance of providing all required information.
Revision Process	If there are changes to the project schedule, the revision number must be marked on the form and submitted at least 24 hours prior to the change.
Contact Information	Firms must provide contact details, including the contractor's name and phone number, to facilitate communication.
Scope of Work	The form requires a detailed description of the work to be performed, including interior and exterior activities related to lead abatement.

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