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pdfUS 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
| File Type | application/pdf |
| File Title | Lead-Based Paint Activities and Renovation Training Notification |
| Subject | EPA, lead, lead-based paint, lead paint, dust, soil, paint, lead poisoning, lead-based paint, hazard, residential, training noti |
| Author | EPA/OPPTS/OPPT/NPCD |
| File Modified | 2009-12-15 |
| File Created | 2009-06-05 |