Attachment 1- Form 8500-27

Form Approved OMB No. 2070-0195 Expires x/xx/2024

U.S. ENVIRONMENTAL PROTECTION AGENCY

APPLICATION FOR FIRMS
TO CONDUCT LEAD-BASED PAINT ACTIVITIES AND/OR RENOVATIONS

Important: This application is required by 40 CFR §745.89(a) for renovations and is a substitute for the letter required by
§745.226(f)(2) for abatement. Consult the instructions for firms applying for certification to conduct lead-based activities or renovations.
For abatement activities, persons seeking individual certification should use the Application for Individuals instead of this form. Please
fill out all sections. Type or print responses in black or blue ink only.
A.

Application Type (select only one box from Option 1, 2, 3 or 4 of Section A)
1.

2.

3.

Option 1: Renovation, Repair, and Painting (RRP and Dust Sampling Technician) Firm Certification
Initial
Recertification
or
Renovation, Repair and Painting Firm Certification ($300)
or
Option 2: Abatement (Abatement, Risk Assessment, and Inspection) or Abatement/RRP Combination Firm Certification
Initial
Recertification
or
Abatement Firm Certification ($550 for first jurisdiction and
$35 for each additional jurisdiction – list jurisdiction(s) below)
Initial
Recertification
or
Combination Abatement/RRP Firm Certification ($550
for RRP and one abatement jurisdiction, $35 for each
additional abatement jurisdiction – list abatement jurisdiction(s) below)
List abatement jurisdiction(s):
1)___________________ ($550) 2) ____________________ ($585) 3) ____________________ ($620)
(Please note, if applying for more than three jurisdictions add an additional $35 for each jurisdiction and list them on a
separate sheet of paper)
or
Option 3: Amend Existing Certification
Update firm information (no fee required)

Add abatement jurisdiction ($35 per abatement jurisdiction)
List abatement jurisdiction(s) being added to your existing certification:
1) ____________________($35) 2) __________________($70) 3) ________________($105)
or

4.

Option 4: Replace Certificate
Replace Certificate ($15)

B. Enter total application fee $_________________________
Note 1: See instructions for additional fee information and examples of required fees.
Note 2: If you are a federally recognized Indian Tribe seeking certification as a firm check yes in the question below and see Fees
Schedule in the instructions to determine fee required.
Yes
No
Indicate whether you are a federally-recognized Indian tribe seeking certification as a firm.
C. Applicant Information
Name of Firm:
Business Address:

Street Address, Suite Number (Please no P.O. Box)

Mailing Address:

(if different from above) Street Address, Suite Number

Name of Attesting Individual:
Firm’s Phone #:

Last

ext #:

City

State

Zip Code

City

State

Zip Code

First

Attesting Individual’s Phone #:

Middle

ext.

Attesting Individual’s E-mail Address:
EPA Form 8500-27 (Rev 1/13)

Page 1 of 2

Form Approved OMB No. 2070-0195 Expires x/xx/24

D. Website Listing
Once certified your firm will be listed on EPA’s web based search tool. Please select the type of service(s) your firm will
provide:
Renovation
Evaluation
Lead Abatement
E. Lead-Based Paint Activity or Renovation Violation[s]
Does the firm have any past, present, or pending lead-based paint violations of EPA,
State, U.S. territory, or Indian tribal land(s) regulations? If yes, please attach a written explanation.

Yes

No

F. Certification Statement
I hereby attest and affirm the following:

The information included on this application, including any attachments, is true and accurate to the best of my belief and
knowledge.

This firm shall only employ appropriately qualified individuals to conduct lead-based paint activities and renovations.

This firm and its employees shall follow the work practice standards set forth in 40 CFR § 745.227 for conducting lead-based
paint activities or 40 CFR § 745.85 for conducting renovations at all times.

I acknowledge that any certification issued pursuant to this application, including any attachments, will be subject to revocation
if issuance was based on incorrect or inadequate information that materially affected the decision to issue the certification.

____________________________________________
Attesting Individual’s Signature

__________________________/_____/_______
Title
Date Signed

(Please sign legibly within the boundaries of the box above.)

Privacy Act Statement: Authority: 40 C.F.R. Part 745, and 15 U.S.C. §§ 2682 and 2684. Purpose: Information collected in this system is used to establish an
applicant’s eligibility for 1) certification to conduct lead-based paint and renovation, repair and painting (RRP) activities in target housing and child-occupied
facilities; and 2) accreditation to teach lead-based paint and RRP activities training courses. In addition, certification and accreditation information, as well as
information collected from required notifications are used for compliance monitoring, enforcement purposes, and related research. Routine Uses: EPA may
disclose collected information as necessary pursuant to the routine uses published in the Privacy Act System of Records Notice: Federal Lead-based Paint
Program (FLPP) System of Records, EPA-54, F.R. 87 Fed. Reg. No. 201 (October 19, 2022), found at https://www.federalregister.gov/
documents/2022/10/19/2022-22271/privacy-act-of-1974-system-of-records. Such disclosures may include, but are not limited to, disclosure to the
appropriate federal, state, local, foreign, tribal or other public authority where relevant to the issuance or retention of a license, grant, or other benefit; to
contractors, grantees, consultants, volunteers, educational institutions, or research organizations for research purposes; or to contractors, grantees,
consultants, or volunteers as necessary to perform their duties or activities for the Agency. Mandatory or voluntary disclosure and the effects on the
individual of no providing information: Providing your personal information is voluntary. However, failure to provide your personal information may prevent
the Agency from certifying an applicant to perform lead-based paint or RRP activities, or accrediting training programs to teach lead-based paint and RRP
activities training courses.
Paperwork Reduction Act: This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No.
2070-0195). Responses to this collection of information are mandatory (40 CFR 745). An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this
collection of information is estimated to range from 2 to 9 hours per response. Send comments on the Agency’s need for this information, the accuracy of the
provided burden estimates and any suggested methods for minimizing respondent burden including through the use of automated collection techniques to
the Director, Information Engagement Division, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460.
Include the OMB control number in any correspondence. Do not send the completed form to this address.

EPA Form 8500-27 (Rev 1/13)

Page 2 of 2