ALRP IRC Practices Filing Extension Request Form

Do you need additional time to bring your pre-1978 residential rental property, child care or school into compliance with the Vermont Lead Poisoning Prevention Law, Inspection, Repair and Cleaning (IRC) Practices? Use this form to request a deadline extension from the Health Department. If you have multiple properties that need extensions, submit one form per property. Be prepared to provide additional information, such as photos, if requested by the Health Department.

1. Have you recently been contacted by the Asbestos and Lead Regulatory Program (ALRP) about possible lead or asbestos regulation violations at this property? If yes, we will connect your responses here to our investigation. This will help us resolve the investigation. *This question is required.

2. Today's date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. Property owner's first and last name *This question is required.

4. Property Information (provide this information for the property for which you are seeking an IRC Practices filing extension). *This question is required.

Street address
Unit number
City
State
Zip code
Original date of construction
Number of units in building or number of units you own

5. Property type *This question is required.

6. Property Owner or Manager Information

Please enter the following information for the person responsible for filing the annual IRC Practices statement for this property *This question is required.

First and last name
Date of birth
Company
Mailing address (enter P.O. Box if used)
City
State
Zip code
Phone number
Email address

In the past 365 days, which IRC Practices have or have not been performed by an IRC Practices certified person on the property?

This section asks you about all the required IRC Practices activities for the property so that you can indicate the ones you have completed already and request an extension for the ones for which you need more time. An IRC/EMP certified person may have partially completed an IRC Practices activity at the property but need more time to complete it in all units. Describe this in the text box that appears when you indicate that the activity has not been completed.

7. Inspection of all the interior rooms and common areas in the property that the tenants have access to *This question is required.

8. What is the name and certificate number of the person who performed the interior inspection?
*This question is required.

First and last name
IRC Practices or EMP certificate number

8. Describe:
1) why an IRC/EMP certified person was unable to inspect the interior of this property. List the units in which the interior inspection was not able to be performed and why.
2) your plan for having an IRC/EMP certified person perform the interior inspection(s) *This question is required.

8. Enter the date by which an IRC/EMP certified person will have performed the interior inspection. You must choose a date that is no later than 30 days from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. Was deteriorated paint in excess of 1 square foot per room found? *This question is required.

8. Was the deteriorated paint repaired by a Vermont RRPM firm and supervisor licensed or UCCO certified person? *This question is required.

8. What is the name and Vermont RRPM supervisor license or UCCO certificate number of the person who completed the repair? *This question is required.

First and last name
RRPM supervisor license or UCCO certificate number

8. Describe:
1) where the deteriorated paint is located
2) why you were unable to repair the paint before the IRC Practices filing deadline
3) how you blocked tenant access to the deterioration and
4) your plan for completing the repair by an Vermont RRPM licensed or UCCO certified individual *This question is required.

8. Enter the date by which the interior paint repair will have been completed. You must choose a date that is no later than 30 days from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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8. Describe what you have done to prevent tenants or the children, family members and staff at the child care or school from accessing the deteriorated paint (this could include installing barriers, wrapping deteriorated paint with plastic sheeting, etc.). *This question is required.

8. Inspection of all the exterior surfaces that the tenants have access to (including garages and other structures) *This question is required.

9. What is the name and IRC/EMP certification number of the person who performed the exterior inspection? *This question is required.

First and last name
IRC/EMP certificate number

9. Describe:
1) why an IRC/EMP certified person was unable to inspect the exterior of this property
2) your plan for having an IRC/EMP certified person perform the exterior inspection *This question is required.

9. Enter the date by which an IRC/EMP certified person will have performed the exterior inspection. You must choose a date that is no later than 30 days from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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9. Was deteriorated paint in excess of 1 square foot per exterior surface found? *This question is required.

9. Was the deteriorated paint repaired by a Vermont RRPM licensed or UCCO certified person? *This question is required.

9. What is the name and Vermont RRPM supervisor license or UCCO certificate number of the person who completed the repair? *This question is required.

First and last name
RRPM supervisor license or UCCO certificate number

9. Describe:
1) where the deteriorated paint is located
2) why you were unable to repair the paint before the IRC Practices filing deadline
3) how you blocked tenant access to the deterioration and
4) your plan for completing the repair by a Vermont RRPM licensed or UCCO certified individual *This question is required.

9. Enter the date by which the exterior paint repair will have been completed. You must choose a date that is no later than 6 months from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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9. Describe what you have done to prevent tenants or the children, family members and staff at the child care or school from accessing the deteriorated paint (this could include installing barriers, wrapping deteriorated paint with plastic sheeting, etc.). *This question is required.

9. Inspection of window well inserts to confirm they are in place and in good repair *This question is required.

10. What is the name and IRC/EMP certificate number of the person who inspected the window well inserts? *This question is required.

First and last name
IRC/EMP certificate number

10. Describe:
1) why the window well inserts were not inspected
2) your plan for having an IRC/EMP certified person perform the window well insert inspection *This question is required.

10. Enter the date by which the window well inserts will have been inspected. You must choose a date that is no later than 30 days from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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10. Were there window well inserts in all the pre-1978 windows and were the inserts in good repair? *This question is required.

10. Describe:
The location(s) of missing or damaged window well inserts
The plan for installing or repairing the inserts *This question is required.

10. Annual specialized cleaning of common areas *This question is required.

11. What is the name and IRC/EMP certificate number of the person who performed the specialized cleaning of the common areas? *This question is required.

First and last name
IRC/EMP certificate number

11. Describe:
1) why an IRC/EMP certified person was unable to perform specialized cleaning in the common areas
2) your plan for having an IRC/EMP certified person perform specialized cleaning in the common areas *This question is required.

11. Enter the date by which the specialized cleaning of common areas will have been completed. You must choose a date that is no later than 30 days from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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11. By which date will the annual IRC Practices compliance statement be filed for this property? You must choose a date that is no later than 6 months from today. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Tenant, staff and parent information

12. Did you notify your tenants that the property is not in compliance with the Vermont Lead Poisoning Prevention Law and provide them with “Protect Your Family from Lead in Your Home” pamphlet and "Vermont Lead Law: What Landlords and Child Care Providers Need to Do" information sheet? *This question is required.

Certify that each of the following statements is true by checking the box next to the statement

13. I understand that my property is not fully compliant with the Vermont Lead Poisoning Prevention Law/Inspection, Repair and Cleaning Practices until I have completed the tasks for which I am requesting an extension and I have filed an annual Compliance Statement. *This question is required.

14. I further certify that this request for more time to complete Inspection, Repair and Cleaning Practices and file the Compliance Statement is true and correct. *This question is required.

15. I understand that providing false, incomplete or inaccurate information on this form is unlawful and is punishable by civil and criminal penalties pursuant to Vermont law. *This question is required.

16. Please use this space to leave any additional comments or information for this extension request.

ALRP IRC Practices Filing Extension Request Form

Extension Request: Vermont Lead Poisoning Prevention Law, Inspection, Repair and Cleaning Practices