9600-052 Notification Form

Form Approved OMB No. 2070-0195 Expires 2/29/24

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/
EPA Form 9600-052

Privacy Act Statement
Authority: 40 C.F.R. Part 745, and 15 U.S.C. §§ 2682 and 2684.
Purpose: Information collected in this system is used to establish an applicant’s eligibility for 1)
certification to conduct lead-based paint and renovation, repair and painting (RRP) activities in target
housing and child-occupied facilities; and 2) accreditation to teach lead-based paint and RRP activities
training courses. In addition, certification and accreditation information, as well as information collected
from required notifications are used for compliance monitoring, enforcement purposes, and
related research.
Routine Uses: EPA may disclose collected information as necessary pursuant to the routine uses
published in the Privacy Act System of Records Notice: Federal Lead-based Paint Program (FLPP) System
of Records, EPA-54, F.R. 87 Fed. Reg. No. 201 (October 19, 2022), found at https://
www.federalregister.gov/documents/2022/10/19/2022-22271/privacy-act-of-1974-system-of-records.
Such disclosures may include, but are not limited to, disclosure to the appropriate federal,
state, local, foreign, tribal or other public authority where relevant to the issuance or retention of a
license, grant, or other benefit; to contractors, grantees, consultants, volunteers, educational
institutions, or research organizations for research purposes; or to contractors, grantees, consultants, or
volunteers as necessary to perform their duties or activities for the Agency.
Mandatory or voluntary disclosure and the effects on the individual of not providing
information: Providing your personal information is voluntary. However, failure to provide your personal
information may prevent the Agency from certifying an applicant to perform lead-based paint or RRP
activities, or accrediting training programs to teach lead-based paint and RRP activities
training courses.

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501
et seq. (OMB Control No. 2070-0195). Responses to this collection of information are mandatory (40
CFR 745). An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The public reporting
and recordkeeping burden for this collection of information is estimated to range from 0.2 to 0.5 hours
per response. Send comments on the Agency’s need for this information, the accuracy of the provided
burden estimates and any suggested methods for minimizing respondent burden including through
the use of automated collection techniques to the Director, Regulatory Support Division, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this
address.