Form Sample Form Sample Form Lead-Based Paint Activities and Renovation Training Noti

US Environmental Protection Agency

Lead-Based Paint Activities and Renovation

Important: The training program manager may complete this sample form or similar form when notifying the EPA. Consult the
Instructions for Notifying the EPA of Lead-Based Paint Abatement Activities and Renovation Courses when preparing training
notification. Please type or print responses in black or blue ink only.

A. Type of Notification

Original

Updated

Cancellation

(Choose one)

B. Description of Training
Course Discipline:
(Choose one)

Course Type:

Worker
Supervisor
Inspector
Risk Assessor
Project Designer
Renovator
Dust Sampling
Technician

Date(s)

Initial
Refresher

(Choose one)

Start Time

Language Presented:

English
Spanish
Other_______

(Choose one)

End Time

Month/Day/Year

am

/

pm

am

/

pm

am

/

pm

am

/

pm

am

/

pm

am

/

pm

am

/

pm

am

/

pm

Principal Instructor:____________________________________________________________________________________
Training Location Name (if applicable):_____________________________________________________________________
Training Location Address:______________________________________________________________________________
Street Address

______________________________________________________________________________
City

State

Zip Code

Training Location Phone Number:_______________________________

C. Training Program
Name:________________________________________

Accreditation Number:_______________________________

Address:_____________________________________________________________________________________________
Street Address

City

State

Zip Code

Phone Number:_______________________________

D. Training Managers Information

(Please note that this form is incomplete without a signature)

I hereby attest and affirm that the information included on this notification form is true and accurate to the best of my belief and
knowledge. I acknowledge that any approval authorized pursuant to this notification will be subject to revocation if issuance
was based on incorrect or inadequate information that materially affected the decision to issue the approval.
Name_____________________________

Signature__________________________

Date Signed_________________

For information on EPA and other lead programs, see the web site:
http://www.epa.gov/lead