Form Sample form - Pre- Sample form - Pre- Lead-Based Paint Activities Training Notification Sample

U. S. E NVIRONMENTAL P ROTECTION A GENCY

L EAD -B ASED P AINT A CTIVITIES

TRAINING NOTIFICATION

Important: The training program manager may complete this sample form or a similar form when notifying EPA.
Consult the Instructions for Notifying EPA of Lead-Based Paint Abatement Activities Courses when preparing t r a i n i n g
notification. Please type or print responses in black or blue ink only.
A. Type of Notification

Original

Updated

Cancellation

(choose one)

B. Description of Training
Course Discipline:
Worker
(choose one)

Course Type:

Supervisor

(choose one)

Initial
Refresher

Inspector

Language
Presented:

English

(choose one)

Other:

Spanish

Risk Assessor
Project Designer

Date(s)

Start Time

End Time

Month/Day/Year

am/

pm

am/

pm

am/

pm

am/

pm

am/

pm

am/

pm

am/

pm

am/

pm

Principal Instructor:
Training Location Name (if applicable):
Training Location Address:
Street Address
City

State

Zip Code

Training Location Phone Number:
C. Training Program
Name:

Accreditation Number:

Address:
Street Address

City

State

Zip Code

Phone Number:
D. Training Managers Information

(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

For information on EPA and other lead programs, see the web site:
http://www.epa.gov/lead