Public Participation and Permit Support Division

ASBESTOS ACCREDITATION AFFADAVIT (AAC-1) Louisiana Department of Environmental Quality For LDEQ Use Only Office of Environmental Services Ck. No. M.O. No. Public Participation and Permit Support Division Notifications and Accreditations Section Date Amt. P.O. Box 4313, Baton Rouge, LA 70821-4313 $ Physical Address: 602 N. 5th St, BR, LA 70802 Phone (225) 219-3250 (This form must be received by mail or hand-delivered. No faxed applications will be processed.) I. Applicant Information (Print legibly or type) EMERGENCY: YES NO (Explanations of fees are noted in Section III.)

Name Accreditation Renewal Yes No AI No. Home Address Apt No. Email

City State Zip

Phone No. ( ) Yes No Has status as a Registered Architect, Engineer, or CIH changed? Date of Birth

Driver’s License/State ID No. Issuing State of Driver’s License/State ID Louisiana Other______

Company Phone no. ( )

Address

City State Zip

Email for PDF Certificates II. Check Accreditations Desired Complete one application only for one or more disciplines. Worker Contractor/Supervisor Inspector Management Planner Project Designer III. Fees Workers: Normal Processing: $ 73 Emergency: $ 109 All Others (per Discipline): Normal Processing: $ 291 Emergency: $ 436 (Emergency applications are processed in approximately 5 working days) FEES ARE NON-TRANSFERABLE / NON-REFUNDABLE–No Cash Accepted (Check or Money Order Only, Payable to LDEQ) IV. Qualifications for Accreditations 1. Attach copy of initial and all refreshers for first time applicants. Originals will not be returned. Renewals attach applicable refresher training(s). 2. If training not received from a Louisiana recognized training provider, provide proof of La. 2-hr regulations per LAC 33:III.Chapters 27 & 51. 3. Attach full face picture for each accreditation desired - Cut EXACTLY 1” X 1 ¼” & labeled with applicant’s name on back. 4. Inspectors (first time only) submit copy of high school diploma or highest level of education received, the minimum being a GED. 5. Management Planners (first time only) provide proof as Registered Architect, Engineer, CIH, or related scientific field. 6. Project Designers (first time only) provide proof as Registered Architect, Engineer, or CIH.

V. Regulation Knowledge and Enforceability I have an updated copy of the Louisiana Administrative Code, Title 33, Part III. Chapters 27 and 51.Subchapter M, including the revisions, which pertain to Asbestos regulations. I have read and understand the Louisiana regulations. I am aware that in accordance with La. R.S. 30:2025.F.2, any person who knowingly and intentionally makes any false statement, representation or certification in any document filed or required to be maintained, shall upon conviction be punished by a fine of not more than twenty-five thousand dollars ($25,000) or imprisonment for not more than 1 year, or both. In addition, I understand that, under Privacy Act 5 USC 552(a), my personal information is being given voluntarily and may be used by the Louisiana Department of Environmental Quality to verify my identity. Applicant’s Signature ______Date: ______

VI. Validity of Accreditation Note: Continuous accreditation will be maintained with the same annual expiration/renewal date provided you submit the required documents and receive refresher training within 90 days prior to your expiration/renewal date. form_7076-e_r02 Revised 07/10/2017