Get The Mold Inspection Report Form Details

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QuestionAnswer
Form NamePc326 Mdr 1 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescertificate of mold damage remediation form, mold remediation invoice template, mold remediation invoice, mold

Form Preview Example

Te x a s De pa rt me nt of I nsura nce

Property and Casualty Section – Personal and CommercialOf Lines Office

Mail Code 104-PC, 333 Guadalupe P. O. Box 149104, Austin, Texas 78714-9104 512-305-6711 telephone 512-490-1014 fax www.tdi.texas.gov

CERTIFICATE OF MOLD DAMAGE REMEDIATION

Certificate Number

 

 

 

 

 

 

 

Date of Issuance

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

State

 

 

 

 

 

 

Zip

 

 

Property Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number

 

 

Street

 

 

 

 

 

 

 

Lot

 

 

 

Block

 

 

Addition or Tract

 

 

 

City

 

 

 

 

County

 

 

 

 

 

SIGN APPROPRIATE CERTIFICATION

Mold Assessment Consultant License Holder Certification

I hereby certify that based on visual, procedural and analytical evaluation, the mold contamination identified for this project has been remediated as outlined in the mold management plan or remediation protocol.

I further certify with reasonable certainty that the underlying cause or causes of the mold that were identified for this project in the mold management plan or remediation protocol have been remediated. A copy of the written evaluation that forms the basis for my certification has been provided to the person named in this certificate.

Mold Assessment Consultant

 

Department of State Health Services

 

Date

License Holder Signature

 

License No. and Expiration Date

 

 

OR

Mold Remediation Contractor License Holder Certification

I hereby certify that I completed mold remediation on this project and will provide the mold remediation certificate to the property owner no later than the 10th day after the date of completion.

Mold Remediation Contractor

 

Department of State Health Services

 

Date of Completion

License Holder Signature

 

License No. and Expiration Date

 

 

OR

Mold Assessment Consultant or Adjustor License Holder Certification

I hereby certify that I have inspected the property described in this certificate and that based on my inspection I have determined that the property does not contain evidence of mold damage. A copy of the written evaluation that forms the basis for my certification has been provided to the person named in this certificate.

 

Mold Assessment Consultant/Adjustor

 

Department of State Health Services

 

Date

 

 

License Holder Signature

 

License No. and Expiration Date

 

 

 

 

 

 

 

 

 

 

PC326 MDR-1 (Rev. Eff. 12/15/05)

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