Pc326 Mdr 1 Form PDF 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 namesirs, certificate of mold damage remediation, certificate of remediation, certificate of mold damage remediation texas

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PC326 MDR-1| Eff. 12/15/05

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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

 

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

 

Texas Department of Insurance | www.tdi.texas.gov

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mold remediation invoice gaps to fill in

Write down the data in I further certify with reasonable, Mold Assessment Consultant License, Department of State Health, Date, Mold Remediation Contractor, I hereby certify that I completed, Mold Remediation Contractor, Department of State Health, Date of Completion, Mold Assessment Consultant or, I hereby certify that I have, Mold Assessment ConsultantAdjustor, Department of State Health, and Date.

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In the Texas Department of Insurance area, identify the significant particulars.

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