Winnebago County Health Department

WINNEBAGO COUNTY HEALTH DEPARTMENT Mail To: P.O. Box 4009, Rockford, IL 61110 401 Division Street Rockford, IL 61104 PH: (815) 720-4100

LEAD-WATER INSPECTION FORM – FEE $45.00

INSTRUCTIONS: Return this Lead-Water Inspection/Agreement Form to the address shown above, together with your FHA/VA Loan Inspection Application and the total fee of $205.00 (this fee of $205.00 already includes the $45.00 for your lead inspection)

APPLICANT’S AGREEMENT:

I agree not to turn on or flush water for a minimum of six (6) hours prior to sample collection. I understand flushing or use of water will invalidate this lead test.

______Signature Print Name

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WINNEBAGO COUNTY HEALTH DEPARTMENT Mail To: P.O. Box 4009, Rockford, IL 61110 401 Division Street Rockford, IL 61104 PH: (815) 720-4100

LEAD-WATER INSPECTION FORM – FEE $45.00

INSTRUCTIONS: Return this Lead-Water Inspection/Agreement Form to the address shown above, together with your FHA/VA Loan Inspection Application and the total fee of $205.00 (this fee of $205.00 already includes the $45.00 for your lead inspection)

APPLICANT’S AGREEMENT:

I agree not to turn on or flush water for a minimum of six (6) hours prior to sample collection. I understand flushing or use of water will invalidate this lead test.

______Signature Print Name