DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY FOR L&I USE ONLY002 Cert #:002 Date:002 APPLICATION FOR LEAD OCCUPATION CERTIFICATION002 IMPORTANT: READ INFORMATION ON PAGES 2 and 3 BEFORE COMPLETING APPLICATION.002 PLEASE TYPE OR PRINT NEATLY IN INK Type of Application Initial 226 1st time applying to Pennsylvania Personal First Name Middle Initial Data City State Zip Code County Telephone Email Eye Color (CIRCLE one): Alternate Mailing listed above in Personal Data, please complete the following information. This address will be Address printed on the license/ID card. Mailing Address City State Zip Code Telephone Email Employment Abatement Company222s Name Information Street Address City State Zip Code Abatement Company222s Telephone Are you a PA State Employee? Yes No If 223Yes224, list Agency Categories 1. Worker 2. Supervisor 3. Project Designer 4. Building Inspector 5. Risk Assessor 6. Building Inspector and Risk Assessor NOTE:Supervisor, you must complete an application for each employer (Application fee only needs paid once). Signature By signing this document, I certify that the above information is correct and that within the past not been suspended or revoked by any other state, and that no enforcement actions are pending against me. Applicant Name (Printed or Typed): Applicant Name (Signed): Date Signed: FOR L&I USE ONLY Check #: Amount:$ Bates #: LIBI-607L REV 11-18 (Page 1 of 3) American LegalNet, Inc. www.FormsWorkFlow.com Training Required IMPORTANT: Pennsylvania does not allow for 223gaps in Lead training224. Lead training taken in Pennsylvania by an accredited Lead Training Provider is valid for three (3) years. Every state regulates their own Lead program differently and training validity periods vary from state to state. It is your responsibility to know APPLICANTS WHO ARE APPLYING WITH PENNSYLVANIA TRAINING: If you have taken Initial Lead training in Pennsylvania and this is your 1st time applying for a Worker or 1. Worker 226 Along with a completed application and fee, you need to provide a copy of your Lead 2. Project Designer 226 Along with a completed application and fee, you need to complete and submit If you have taken Initial Lead Training in Pennsylvania and this is your 1st time applying for a Supervisor, andNOTE: Every applicant must take the 1. 003Supervisor Lead Supervisor for a Lead Abatement Contractor, you may submit the Application for Lead 2. 003Building Inspector 3. 003Risk Assessortaken since you last applied, along with a completed application and applicable fee. APPLICANTS WHO ARE APPLYING WITH OUT-OF-STATE TRAINING: If you have taken Initial Lead training from a training provider outside of Pennsylvania and this is your 1st time1.003 Workerin your Worker training. 2.003 Project DesignerDesigner training. LIBI-607L REV 11-18 (Page 2 of 3) American LegalNet, Inc. www.FormsWorkFlow.com If you have taken Initial Lead Training outside of Pennsylvania and this is your 1st time applying for a andNOTE: Every applicant must take the EPA Third Party need to submit the following: 1. Supervisor 226 You will need to complete and submit the Registration for Lead Occupation Supervisor for a Lead Abatement Contractor, you may submit the Application for Lead Contractor 2. Building Inspector 226 You will need to complete and submit the Registration for Lead Occupation 3. Risk Assessor 226 You will need to complete and submit the Registration for Lead Occupationtaken since you last applied, along with a completed application and applicable fee. Validation Period Prior Enforcement Action indicating that the applicant222s abatement work might not be performed in a manner that would protect public health, safety and welfare. If enforcement action has been taken against the applicant, the following information must be submitted: 1. A complete list of all prior enforcement actions, including any sanctions imposed upon the applicant 2. A description of any Lead abatement activities conducted by the applicant that were terminated prior to completion, including the circumstances of termination. 3. A copy of any reports compiled by an enforcement agency. Filing FEE SCHEDULE:Requirements and Fees schedule by email Make all checks and money orders payable to the Commonwealth of Pennsylvania. Mail this application, your payment and any additional documentation to: PA Department of Labor & Industry 651 Boas Street, Room 1606 Harrisburg, PA 17121 . 002003002003Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBI-607L REV 11-18 (Page 3 of 3) American LegalNet, Inc. www.FormsWorkFlow.com