Attachment 4 -Form 9600-050

Form Approved OMB No. 2070-0195 Expiresxx/xx24
Lead-Based Paint Activities and Renovation

US Environmental Protection Agency

Important: The training program manager may complete this sample form or similar form when notifying the EPA. Consult the
Instructions for Notifying the EPA of Lead-Based Paint Abatement Activities and Renovation Courses when preparing training
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:
(Choose one)

Course Type:

Worker
Supervisor
Inspector
Risk Assessor
Project Designer
Renovator
Dust Sampling
Technician

Date(s)

Initial
Refresher

(Choose one)

Start Time

Language Presented:

English
Spanish
Other_______

(Choose one)

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
EPA Form 9600-050

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 childoccupied 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 Leadbased
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-ofrecords. 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 not 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.
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 be 0.2 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.