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PC326 MDR-1| Eff. 12/15/05
CERTIFICATE OF MOLD DAMAGE REMEDIATION
Certificate Number
Name
Date of Issuance
Mailing Address
City State Zip
Property Description:
Number
Addition or Tract
Street
City
Lot
County
Block
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 10
th
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 1/1
