Form 49150 - Notification Of Lead Abatement Activities - Indiana Department Of Environmental Management Page 2

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VIII.

Description of planned activity work to be performed and methods to be employed, including techniques to be used and a description of the affected facility

components.

__________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________

IX.

Description of work practices and engineering controls to be used to comply with this rule, including lead removal and waste handling emission control

procedures.

__________________________________________________________________________________________________________________________________________

Description of procedures to be followed in the event that unexpected lead-based paint becomes a lead-based hazard and warrants immediate action.

__________________________________________________________________________________________________________________________________________

XI.

Waste Transporter

XII.

Lead Disposal Site

Name: _____________________________________________________________

Address: ___________________________________________________________

City: ___________________________ State: __________ Zip: _______________

City: ________________________ State: __________ Zip: __________________

Contact: _______________________________ Phone: ______________________

Contact: _____________________________ Phone: ________________________

XIII.

For Emergencies only:

Date and hour of emergency:

Explanation of how the event caused a lead based paint hazard and warranted immediate action:

XIV.

I hereby certify that this information in this notification is correct and that I will only use Indiana licensed workers and project supervisors, to implement

this lead abatement activity, which have been trained under 326 IAC 13-17-14-5; 40 CFR 745. The trained individual (s) along with evidence that the

required training was accomplished shall be available at the job site during actual work hours.

________________________________________________________________

_________________________________________

owner/operator (signature)

date

________________________________________________________________

_________________________________________

owner/operator (printed)

affiliation

„ „ OFFICE USE ONLY „ „

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