All written notifications shall be submitted on a form provided by the Department of Health and shall include the following:

1. (1) Name, street address, contact person, and telephone number for the building owner;
2. (2) Name, street address, contact person, telephone number, and license number of the licensed lead-based paint contractor or consultant performing the lead-based paint abatement;
3. (3) Scheduled starting and completion dates of the lead-based paint abatement activities;
4. (4) Scheduled work hours;
5. (5) Location and street address of the target house or houses or child-occupied facility or facilities upon which the abatement will be performed, including any apartment number, if applicable;
6. (6) Name, business address, business telephone number, certificate number, and discipline of the person preparing the occupant protection plan and the license number of the firm employing this person for this lead-based paint activity;
7. (7) Work practices to be employed during the abatement;
8. (8) Whether an inspection, risk assessment, or lead-hazard screen has been performed on the structure upon which the abatement will be performed;

9. (9) If an inspection, risk assessment, or lead-hazard screen has been performed, the:

   1. (A) Date performed;
   2. (B) Certificate number, discipline, and name of the individual who performed the lead-based paint activity; and
   3. (C) License number and name of the firm for whom the individual performed the lead-based paint activity;
10. (10) Name, business address, and business telephone number of the laboratory performing any analysis associated with the abatement; and
11. (11) The name, certificate number, and complete telephone number of the supervisor who will be on site and telephone number of the firm employing the supervisor for the particular abatement.