Forms • Hagerstown, MD • CivicEngage

Lead Inspection Result Submission

Leave This Blank:

License #*
Rental Street #*
N/S/E/W
Street Name*
Unit #
Lead Inspection Certificate Number(s) and Date(s) of Inspection*

	I hereby affirm under penalty of perjury that the information on this form with regard to lead poisoning prevention, is true to the best of my knowledge and belief. I also understand if there are any changes in property ownership, owner address or agent/contact information I will notify the Code Administration Office within 10 days of the change.*

Owner's/Agent Name*

* indicates required fields.