Commercial and Industrial Lead Removal
Louisiana Department of Environmental Quality
Office of Environmental Services
Public Participation and Permit Support Division
Notifications and Accreditations Section
P.O. Box 4313, Baton Rouge, LA 70821-4313
Phone (225) 219-3300
For LDEQ Use Only
AI No.
Test Date
Check No.
Check Date
Amt. Rec’d / $
Process. Date
I. Applicant Information (please print or type)
Company Name / Owner /Business Address / City / State / Zip
Email Address / Phone / ( ) / Fax / ( )
Qualifying Party / DL /State ID No.
for Qualifying Party / State of Issuance
II. Certification of Compliance
I, , do hereby certify that:
(Owner/Qualifying Party)
a. workers who conduct lead paint removal activities for the lead contractor are trained in accordance with OSHA and/or SSPC;
b. the lead contractor has access to at least one disposal site permitted to receive lead-contaminated waste that may be generated by the lead contractor during the term of the license;
c. the lead contractor will incorporate appropriate work practice standards, following OSHA and SSPC requirements, so as to prevent the contamination or recontamination of the environment and protect public health from the hazards of exposure to lead;
d. the lead contractor possesses a worker protection and medical surveillance program consistent with the requirements of OSHA;
e. a certified lead supervisor/competent person (SSPC C-3 or equivalent OSHA training) will be available during lead abatement activities;
f. the qualifying party will maintain accreditation as a supervisor/competent person through SSPC (C-3) or maintain OSHA competent person training; and
g. the lead contractor shall maintain all records for not less than 3 years.
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 three (3) years have you performed lead paint removal 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_7071_r01
05/31/2017