Notification of Lead-Based Paint Abatement Activities

NOTIFICATION
U. S. E NVIRONMENTAL P ROTECTION A GENCY

OF L EAD -B ASED P AINT A BATEMENT A CTIVITIES

Important: A representative of the certified firm may complete this sample form or a similar form when notifying EPA.
Co n s u l t t h e I nstructions for Notifying EPA Commencement of Lead-Based Paint Abatement Activities when preparing
abatement notification. Please type or print responses in black or blue ink only.
A. Type of Notification

Please indicate the type of notification.

Original

Updated

Cancellation

No
Yes, if yes include documentation showing evidence of an EBL
B. Emergency Notification
determination or a copy of the Federal/State/Tribal/Local emergency abatement order.
C. Activity Start and End Dates

Specify the dates you will begin and end lead-based paint activity.

If necessary, estimate end date using
your best professional judgment.
D. Description of Activity

End date: ________________

Start date: ________________
Month/Day/Year

Month/Day/Year

This section relates to the building where abatement work will be performed.

Type of Building:
Single Family Dwelling
Multi-Family Dwelling
Property name (if applicable): ___________________________________

Child-Occupied Facility

Property Address including apartment and/or unit number(s):
_________________________________________________________________________________________
Street Address

City

State

Zip Code

Square footage/acreage to be abated: _______
Please write a brief description of abatement project to be performed. (Enclose additional paper if necessary)

E. Firm Information
Name: ___________________________________

Firm’s Certification Number: _________________

Address: __________________________________________________________________________________
Street Address

City

State

Zip Code

Phone Number: ________________________________
F. Certified Supervisor’s Information
Name: ________________________________________________________________________________
EPA Certification Number: ____________________________ (Check here
if working under interim certification
and enter the identification number from your course completion certificate in this space)
G. Firm Affirmation 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 decisio n t o i s s u e
the approval.
Name: ___________________________________

Title: ______________________________________

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