Renovator or Dust Sampling Technician Application for Certification Georgia Environmental Protection Division

Lead-Based Paint & Asbestos Program (404) 363-7026

www.gaepd.org

Discipline Certification Initial or Renewal?

Fee Amount Enclosed Date on Check

Name on Check Check Number Check Amount

Applicant Information This application cannot be used for a Lead Inspector, Lead Risk Assessor, Lead Worker, Lead Project Designer, or Lead Supervisor.

Applicant First Name Applicant Last Name Title

Applicant Home Address

Applicant Home City State Zip

Applicant Date of Birth Gender Height - Feet Inches Weight

Home Phone Number Cell Phone Number

E-Mail Address

Renovation Firm Information It is not necessary to be currently employed by a Georgia Certified Renovation Firm for this application; however, you must be employed by such a firm

while conducting lead-based paint renovation activities.

Renovation Firm Name Contact Person

Firm Address

Firm City State Zip

Firm Phone Number Firm Fax Number

Firm E-Mail Address Website Address

Georgia Renovation Firm Certification Number Expiration Date

Renovator or Dust Sampling Technician Training Information

Georgia Accredited Training Provider Last Date of Course

Course(s) Taken Initial or Refresher

FALSIFYING OR KNOWING OMSSION OF ANY MATERIAL REQUIRED AS PART OF THIS APPLICATION IS GROUNDS FOR APPLICATION REFUSAL AND/OR CERTIFICATION SUSPENSION OR REVOCATION.

I certify under penalty of law that I have personally examined and am familiar with the information submitted in this application and all attached documents, and that the submitted information is true, accurate, and complete. Renovator certification is good for 3 years. Dust Sampling Technician Certification is good for either 1 year or 2 years depending on the amount of fees paid. I agree to work for a Georgia Certified Renovation Firm when conducting lead-based paint renovation activities in target housing or child-occupied facilities in accordance with local, state, and federal regulations.

PLEASE PRINT AND SIGN YOUR APPLICATION: Date Signed

How To Submit This Application

Click on the Print Form Button on the right to print the application. You will need to print two copies. Send one copy of signed application, a copy of your training certificate, and a check or money order for the certification fee to

EPD LEAD RENOVATION FEES POST OFFICE BOX 101896

ATLANTA, GA 30392 DO NOT send original documents to the above address - this is a bank lock box.

Originals sent to the lock box address will be shredded!

Send the other signed copy of the application, your original training certificate, and one color, passport size photo to EPD LEAD-BASED PAINT PROGRAM

ATTN: CERTIFICATIONS 4244 INTERNATIONAL PARKWAY, SUITE 104

ATLANTA, GA 30354

The last step is to e-mail the application to EPD. YOU MUST STILL MAIL ALL MATERIALS AS EXPLAINED ABOVE. We will not mail your certification until we receive all required documentation & fees, but advance e-mailing of your application will expedite the process. Click the button on the right to e-mail your form. The e-mail address is asbestos.leadprogram@dnr.state.ga.us

Instructions for Completion of This Application

All information is to be filled out completely, typed or printed in ink. Pencil is not acceptable.

Application and Fee Information Please indicate the type of certification requested, chose one or the following: Renovator - Certification for 3 Years Dust Sampling Technician - Certification for 1 Year Dust Sampling Technician - Certification for 2 Years Individuals applying for certification for the first time will enter "Initial." Enter "Renewal" on subsequent applications submitted in order to maintain certification for your discipline. Initial and renewal certifications have the following expiration periods: Renovator Certifications expire on the 36th month (3 years) from the last day of training. Dust Sampling Technician Certifications expire either every 12 months (1 year) or every 24 months (2 years) from the last day of training or date of issuance, whichever is earlier. Expiration of the Dust Sampling Technician Certification also depends on the amount of fees paid. Fee Amount Enclosed - Annual Fee Schedule: $150 for 3-Year Renovator Certification $150 for 1- Year Dust Sampling Technician Certification $275 for 2-Year Dust Sampling Technician Certification Make the check or money order payable to EPD Lead Renovation Fees and follow the directions above for submitting the application. Do not send cash. Renovation Firm Information It is not necessary to be currently employed by a Georgia Certified Renovation Firm for this application; however, you must be employed by such a firm while conducting lead-based paint renovation activities. Training Information Please provide the name of the Georgia accredited training provider, the name of the training course, whether it was the initial or refresher course, and the last day of the course. Send the original training certificate with the application to the EPD Office address.Please refer to http://www.gaepd.org/Documents/index_land.html under the "Permitted Facilities and Licensed Contractors" for "Lead-Based Paint Renovation Contractors" to find the current listing of Georgia accredited lead-based paint renovation training providers. Refresher training for the Renovator is required 36 months (3 years) from the date of the initial or subsequent refresher training. Dust Sampling Technician refresher training is required every 24 months (2 years) from the last day of initial or subsequent refresher training. You original training certificate will be returned with the denial of the application or with Georgia certification. Affidavit of Applicant The applicant shall sign and date the application. Applications are not complete and will not be processed if the application is not signed.

For additional information, please contact Georgia Lead-Based Paint and Asbestos Program at (404) 363-7026Form RRP Person