Contact 1 — Salus Lead Services, LLC

Responsible Party Information Form

In order to upload results to the Philadelphia Department of Health portal, we will need some information from you. Once we upload your results, we will send you a portal submission confirmation along with your lead-safe certificate.

By completing this form, you certify that you are the authorized person to submit this information.

Name of Person Completing This Form

First Name

Last Name

What is your email address?

Property Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Property Owner

Number of Bedrooms (please include even if not being used as a bedroom). For multi-units, please note unit name/number & number of bedrooms each.

Does a child age 6 or under reside at this address?

For multi-units, please note which units have children age 6 or under in the Other Information field at the bottom.

Do you already have a rental license?

If applicable, what is your rental license number?

Is the responsible party an individual or company?

If Company- what is the company name?

What is the responsible party name (personal responsible)?

Responsible Party Phone Number

(###)

###

####

Responsible Party Email Address

Responsible Party Mailing Address (P.O. boxes not permitted)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you want us to upload the results to the Dept of Health Portal for you?

Other Information

Please put information for multi-units here (Unit names/numbers, # of bedrooms each, and whether or not a child under the age of six lives in the unit).

Responsible Party Information Form

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Salus Lead Services, LLC

Mailing Address

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