Mississippi Office of Pollution Control
Lead-Based Paint Abatement/Renovation Notification
Project Type:
Abatement
Renovation
Date of Building Construction: _____________
Please check all applicable boxes for the type of Notification:
Original
Revision
Cancellation
Emergency
Please check if asbestos notification was also submitted for this project:
I.
PROJECT/SITE INFORMATION
Target Housing :
Single Family Residence
Multifamily Dwelling * (i.e. multifamily apartment, duplex, etc.)
Child-Occupied Facility
Daycare
Pre-School
Other _________________________________________
Physical Address Project Site ___________________________________________________
City ______________________________ State ____________ Zip Code: _________County: _________________________
Number of Units to be Abated/Renovated in the Building________________________________________________________
II.
BUILDING OWNER INFORMATION
Mr./Mrs._______________________________________________________________________________________________
Address of Owner: __________________________________ City ______________________ State _______ ZIP __________
Telephone Number ________________________________
III.
ABATEMENT/RENOVATION CONTRACTOR INFORMATION
Name of Certified Lead Abatement/Renovator Firm _________________________________________________________
Firm Certification Number _________________ Telephone Number ______________ Exp. Date ________________
Address of Certified Firm ___________________________________________________________________________
City ___________________________________ State ___________________ Zip Code _________________________
IV.
INSPECTION INFORMATION
Name of Inspector/Risk Assessor Conducting Inspection ______________________________________________________
Certification Number _____________________ Exp. Date ____________Date Inspection Conducted _______________
Test Method Used & Manufacturer of Testing Equipment __________________________________________________
For Paint Chip Analysis, Name of Laboratory____________________________Certification Number_______________
V.
GENERAL CONTRACTOR (Other)
Name of Firm ____________________________________________________________________________________________
Firm Mailing Address ______________________________________________________________________________________
Contact Person _______________________________________ Telephone Number ____________________________________
VI.
PROJECT DATES
Lead Project Start ______/______/______
Lead Project Stop _____/_____/______
Day (5 a.m. – 5 p.m.)
Evening ( 5 p.m. – 8 p.m.)
Abatement/Renovation to be done during what time?
Night ( 8 p.m. – 5 a.m.)
Weekend
VII.
DESCRIPTION OF PROCEDURES TO BE USED (CHECK ALL THAT APPLY)
Wet Sanding
Chemical "Removal
Heat Gun
Containment
Strip and Removal
Negative Air
Other – Explain ________________________________________________________________________________________
________________________________________________________________________________________
VIII. DESCRIPTION OF RENOVATION ACTIVITIES TO BE COMPLETED (INCLUDING COMPONENTS TO BE REMOVED)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
LBP Project Notification Form.doc
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