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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 posttraining notification. Please type or print responses in black or blue ink only.
A. Type of Notification
Original
(Please indicate the type of notification)
Updated
B. Training Program
Name:________________________________________
Accreditation Number:________________________________
Address:______________________________________________________________________________________________
Street Address
City
State
Zip Code
Phone Number:_______________________________
C. Course Information
Discipline:
Worker
Renovator
Supervisor
Inspector
Dust Sampling Technician
Type:
Initial
Refresher
Risk Assessor
Project Designer
Training Dates: from________________ to _________________
Month/Day/Year
Month/Day/Year
Training Location Address:________________________________________________________________________________
Street Address
__________________________________________________________________________________________
City
State
Zip Code
D. Student Information (Attach additional paper if necessary)
Name
Date of
Birth
Address
D. Training Managers Information
Course
Certificate #
Course
Test Score
Photo
Included*
(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_________________
*A photo of each student is required for Renovator and Dust Sampling Technician courses.
Please see www.epa.gov/lead/pubs/trainerinstructions.htm for photo specifications. The photos should be sent on a CD along with this form.
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 Post-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 |