Mississippi Office Of Pollution Control Lead-Based Paint Abatement/renovation Notification Form Page 2
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2IX.
WASTE TRANSPORTER
Name ___________________________________________________________________________________________________
Full Mailing Address _______________________________________________________________________________________
City __________________________________________ State ______________________ Zip Code _______________________
Contact _______________________________________________ Telephone Number _________________________________
X.
WASTE LEAD DISPOSAL SITE
Site Name ________________________________________________________________________________________________
Physical Address __________________________________________________________________________________________
Full Mailing Address _______________________________________________________________________________________
City __________________________________________ State ______________________ Zip Code _______________________
XI.
DISPOSAL SITE FOR DEBRIS OTHER THAN LEAD
Site Name ________________________________________________________________________________________________
Physical Address __________________________________________________________________________________________
Full Mailing Address _______________________________________________________________________________________
City __________________________________________ State ______________________ Zip Code _______________________
Contact Person _________________________________________ Telephone Number _________________________________
NOTE: All debris (other than lead) should go to an authorized Rubbish Site, or to a permitted sanitary landfill.
XII. ABATEMENT
A certified supervisor is required for each abatement project and shall be onsite during all work site preparation and during
the post-abatement cleanup and clearance of work areas. At all other times when abatement activities are being conducted,
the certified supervisor shall be onsite or available by telephone, pager, or answering service, and able to be present at the
work site in no more than 2 hours.
XIII. RENOVATION
A certified renovator is required for each renovation project and shall be physically present when the required signs are
posted, while the required work area containment is being established, and while required work area cleaning is performed.
The certified renovator must regularly direct work being performed by other individuals and must be available either on-
site or by telephone at all times renovations are being conducted.
XIV. CERTIFICATION OF ACCURACY
I certify that all of the above information is correct.
Print ______________________________
Signature ______________________________
Date ________________
Contact information for return mail or questions concerning the information on this Notice
Mailing Address _______________________________________________________________________________________
City __________________________________________ State ______________________ Zip Code _______________________
Contact _______________________________________________ Telephone Number __________________________________
Refer to fee schedule to calculate required notification fee. Notification fee must be submitted with notification.
MAIL TO: Mississippi Department of Environmental Quality
Mississippi Department of Environmental Quality
Lead Program
or
Lead Program
PO Box 2261
515 Amite Street
Jackson, MS 39225
Jackson, MS 39201
(601) 961-5171
Revised: 05/2016
LBP Project Notification Form.doc
Page 2
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