Sample form - Post Lead-Based Paint Activities Post-training Notification S

U. S. E NVIRONMENTAL P ROTECTION A GENCY

L EAD -B ASED P AINT A CTIVITIES

POST -TRAINING NOTIFICATION
Important: The training program manager may complete this sample form or a similar form when notifying EPA.
Con s u l t t h e I nstructions for Notifying EPA of Lead-Based Paint Abatement Activities Courses when preparing posttraining notification. Please type or print responses in black or blue ink only.
A. Type of Notification
Original

(Please indicate the type of notification)
Updated

B. Training Program
Name: _________________________________________

Accreditation Number: _____________________

Address:
Street Address

City

State

Zip Code

Phone Number:
C. Course Information
Worker
Supervisor
Inspector
Risk Assessor
Discipline:
Initial
Refresher
Type:
Training Dates: from _____________ to __________________
Month/Day/Year

Project Designer

Month/Day/Year

Training Location Address:_______________________________________________________________
Street Address

______________________________________________________________________________
City

State

Zip Code

D. Student Information (Attach additional paper if necessary)
Name

Address

E. Training Managers Information

Date of Birth

Course
Certificate #

Course
Test Score

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/