Lead Contractor Letter of Approval Application

Lead Contractor Letter of Approval Application LPF-2th Target Housing and Child-Occupied Facility Lead Removal For LDEQ Use Only Louisiana Department of Environmental Quality AI No. Office of Environmental Services Test Date Public Participation and Permit Support Division Check No. Notifications and Accreditations Section Check Date P.O. Box 4313, Baton Rouge, LA 70821-4313 Amt. Rec’d $ Phone (225) 219-3300 Process. Date

I. Applicant Information (please print or type) Company Name Owner Business Address City State Zip Email Address Phone ( ) Fax ( ) DL /State ID No. State of Qualifying Party for Qualifying Party Issuance

II. Certification of Compliance with LAC 33:III. Chapter 28 Requirements I, , do hereby certify that: (Owner/Qualifying Party) a. Each person who conducts lead-based paint activities for the company is annually accredited in accordance with the provisions of LAC 33:III.2807; . The company has access to at least one disposal site permitted to receive lead-contaminated waste that may be generated during the term of the license; c. The company has incorporated the work practice standards in LAC 33:III.2811 so as to prevent the contamination or recontamination of the environment and protect the public health from the hazards of exposure to lead; d. The company possesses worker protection and medical surveillance programs consistent with the requirements of the Occupational Safety and Health Administration (OSHA); e. An accredited lead project supervisor shall be present at all times during the abatement projects; and f. The company shall maintain all records as required by LAC 33:III.2813.

III. Statement of Compliance/Citation This disclosure shall include a signed statement that all penalties and fees assessed to the applicant have been paid in full. (check one) I have not been cited for violating the environmental standards, regulations, or laws of any state or federal regulatory agency. I have been cited for violating the environmental standards, regulation, or laws of any state or federal regulatory agency (include evidence that all penalties and fees assessed have been paid in full). Are you now performing, or in the past five (5) years have you performed lead-based paint activities in other state(s)? Yes No

If yes, please specify state(s) and name of company: ______IV. Letter of Approval Fees for Lead Contractors: $550 for Regular Processing $825 for Emergency Processing Applications for regular processing are reviewed in order of receipt and may take up to 30 days. Applications for emergency processing will be reviewed and processed within five days or less after receipt of the required documentation. Fees are paid to the Louisiana Department of Environmental Quality. Submit application materials and appropriate fees to the address above. FEES ARE NON-TRANSFERABLE AND NON-REFUNDABLE.

V. Statements of Regulation Knowledge and Acknowledgment for Public Records a. I hereby certify that this application, accompanying documents, and information provided is true and accurate in accordance with La. R.S. 30:2025.F(2)(a), which states that any person who willfully or knowingly makes any false statement, representation, or certification in any form, application, record, label, manifest, report, plan, or other document filed or required to be maintained under this Subtitle is subject to penalties with conviction of civil and criminal actions as outlined in this regulation. b. I acknowledge that the information I have provided on or with this form is to be kept in the public records maintained by LDEQ. I also acknowledge that the information will be available for public inspection and copying, and I waive any claim to privacy in this information. Signature of Applicant ______Date ______

Applicant Name (Print) ______

Form_7072_r01 05/31/2017