APPLICATION CHECKSHEET FOR LEAD CONTRACTOR State Form 50745 (R3 / 10-07) INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. INDIANA STATE DEPARTMENT OF HEALTH Lead-based Paint Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250 Do not return this sheet with application. http://www.in.gov/isdh/programs/lead/ 2. This checklist is used by ISDH to review your Form 48739 “Application for Lead Contractor License” and is provided only to assist you in compiling a complete Standard Operating Procedures manual for submittal with the lead contractor license application. FOR OFFICE USE ONLY BY REVIEWER Company name: Applicant name: Designated Representative name: Reviewed by: Date reviewed: TYPE OF LICENSE NEW LICENSE LICENSE RENEWAL - Expiration date: ______/______/______ STATUS APPROVED DENIED PENDING ADDITIONAL INFORMATION PART A: CHECKLIST - GENERAL INFORMATION ► Has the contractor satisfied the following general requirements? YES NO RULE REQUIREMENT General and personal information provided 326 IAC 23-2-4(b)(4) If no, provide the following:___________________________________________________________ 326 IAC 23-2-4(b)(12) Proof of financial responsibility attached Verified: ______________________________________________________________________ 326 IAC 23-2-4(b)(1) Indiana Project Supervisor License Submitted copy of current Indiana lead-based paint Project Supervisor license 326 IAC 23-2(4)(b)(7) Standard Operating Procedures (SOP) Manual Copy of contractor's written standard operating procedures for the following regulatory programs: 326 IAC 1-1; 326 IAC 23-1; 326 IAC 23-4-11; 29 CFR 1926.62; and 29 CFR 1910.134 NOTE: SOP manual should include detailed, specific written procedures for contractor’s compliance with Indiana’s lead laws. This includes notification, work practice, and licensing requirements. PART B: CHECKLIST - 326 IAC 23-4 ► Has the contractor satisfied the following requirements to comply with 326 IAC 23-4? YES NO RULE REQUIREMENT Applicability of Rule NOTE: 326 IAC 23-4-1(a) & (b) Any person or company performing lead-based paint activities shall comply with the appropriate work practices. A political subdivision or a state agency may not accept a bid for a lead-based paint activities project. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Application Checksheet For Lead Contractor 10/07 INDIANA STATE DEPARTMENT OF HEALTH LEAD-BASED PAINT PROGRAM State Form 50745 (R3 / 10-07) PART B: CHECKLIST - 326 IAC 23-4 (continued) ► Has the contractor satisfied the following requirements to comply with 326 IAC 23-4? YES NO RULE REQUIREMENT 326 IAC 23-1-3, 7, & 63 Definitions (adequate quality control, child-occupied facility, target housing) 326 IAC 23-4-6 Indiana notification requirements/contents/schedule/form Lead abatement procedures - interior 326 IAC 23-4-7(1) - (8) Post warning signs Wall to wall carpeting Wrapped with six (6) mil polyethylene Area shall be sealed from non-work areas After sealing off the work area, floors shall be covered, Forced-air heating and air conditioning systems shall be shut down, Alternative entrances and egresses that are located outside of the work area, Work area shall be cleaned with HEPA vacuum Lead abatement procedures - exterior 326 IAC 23-4-8(1) - (3) Uncontained water, and abrasive blasting Before abating lead paint using wet methods on exterior work areas, the following site preparation procedures shall be used: 23-4-8(2)(A-E) Before beginning to abate lead paint using dry methods on exterior work areas, the following site preparation procedures shall be used: 23-4-8(3)(A-D) 326 IAC 23-4-15 Notification fees 326 IAC 23-4-9(1) - (6) Post-abatement clearance procedures Lead-based paint sampling procedures Clearance sampling under section 9 of this rule shall be conducted as follows: 326 IAC 23-4-10(1) - (4) Dwelling will be selected for the random sample. Dwellings are selected for dust sampling. A licensed supervisor or project designer shall prepare a report; the report shall include (A)-(F). PART C: CHECKLIST - 326 IAC 23-4-11; 29 CFR 1926.62 and 1910.134 ► Has the contractor satisfied the following requirements to comply with 326 IAC 23-4-11? YES NO RULE REQUIREMENT 326 IAC 23-4-11(1) - (5) Lead-based paint abatement disposal procedures Follow these procedures when disposing of lead- based paint waste- (1)-(5) Construction Standard: 29 CFR 1926.62 29 CFR 1910.134 Permissible exposure limit Regulated areas Exposure monitoring Engineering controls & work practices Respiratory protection Protective clothing Hazard communications to employees Medical surveillance Respiratory Protection Standards Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Application Checksheet For Lead Contractor 10/07 INDIANA STATE DEPARTMENT OF HEALTH LEAD-BASED PAINT PROGRAM State Form 50745 (R3 / 10-07) PART D: CHECKLIST - 326 IAC 23-2-4(b) ► Has the contractor satisfied the following requirements to comply with 326 IAC 23-2-4(b)? YES NO RULE REQUIREMENT 326 IAC 23-2-4(b)(4) Competency Demonstrated competency in the field of lead project implementation and has read and understands 326 IAC 23 and 40 CFR 745. 326 IAC 23-2-4(b)(6) Prior Contracts A complete list of prior contracts for the previous 36 months for lead projects including names, addresses & telephone numbers of persons for whom projects were performed 326 IAC 23-2-4(b)(8) Terminated Lead Projects A description of any lead-based paint projects which were prematurely terminated or not completed, including circumstances surrounding termination 326 IAC 23-2-4(b)(9) Contractual Penalties A list of any contractual penalties related to lead-based paint activities that contractor has paid for noncompliance with contract specifications 326 IAC 23-2-4(b)(10) Citations/Violations/Findings Copies of any and all citations, notices of violation, or findings of violation levied against the contractor for violations of regulations pertaining to lead abatement and a description of how the allegations were resolved 326 IAC 23-2-4(b)(11) Legal Actions/Claims A description detailing all legal proceedings, lawsuits or claims levied against the contractor or any of his/her past or present employees while employed by the contractor, for lead-based paint related activities PART E: CHECKLIST - OTHER ► Are the following items included with contractor application? YES NO RULE REQUIREMENT 326 IAC 23-2-4(b)(1) White colored lead signature cards signed and attached 326 IAC 23-2-4(e) Two 1-½ inch by 1-½ inch recent color photographs of applicant attached 326 IAC 23-2-4(b)(2) Application signed 326 IAC 23-2-8 Application fee of $150 submitted with application PART F: REVIEWER'S COMMENTS Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com