DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY FOR L&I USE ONLY Project ID: Date: LEAD ABATEMENT NOTIFICATION FORM002 PLEASE TYPE OR PRINT NEATLY IN INK002 Type of Please check one: I(Clearly notate on the form what is being revised) Cancellation Emergency Facility Description (A separate Street Address Apartment/Suite# must be sent for each address, apt., suite #, or Present Use Prior Use(s) common area) Abatement Contractor (Company/ Street Address Supervisor cert info must be listed and must be valid at time Contact Person Telephone of submission and throughout duration of project) Facility Owner Street Address Facility Inspector/Risk Assessor Inspection or Risk Assessment Street Address Date of Inspection/Risk Assessment Other If other, list procedures: FOR L&I USE ONLY Date Postmarked: LIBI-600L REV 02-19 (Page 1 of 3) American LegalNet, Inc. www.FormsWorkFlow.com Operation Schedule of Start Date Completion Date Abatement * * Project TuTh Sa Su PM to AM PM clearance) *Project Description or Attach Company222s Abatement Work Specs -Do Not Use Inspected Items List (attach a this information Description of Material Location of Material Amount/Unit *For revisions, clearly notate what is being revised/ abated during the revised Operation Schedule Detailed Description of Planned Work/Scope of Work (or attach a Lead Abatement not RRP: As Well As Work Practices and Engineering Controls to be Used During LBP Abatement Work LIBI-600L REV 02-19 (Page 2 of 3) American LegalNet, Inc. www.FormsWorkFlow.com Waste Transporter Street Address Contact Person Telephone Waste Disposal Site Street Address Contact Person Telephone Owner/ Operator Signature Title: Date: Filing This form must be mailed to the following address, faxed to 717-705-0196, or emailed Requirements to PA Department of Labor & Industry If approved, a fully completed copy of this form must be faxed or emailed to the 002003002003Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 LIBI-600L REV 02-19 (Page 3 of 3) American LegalNet, Inc. www.FormsWorkFlow.com