DEQ Form 110-303 "Lead-based Paint Certification" - Oklahoma

What Is DEQ Form 110-303?

This is a legal form that was released by the Oklahoma Department of Environmental Quality - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 26, 2015;
  • The latest edition provided by the Oklahoma Department of Environmental Quality;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DEQ Form 110-303 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

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Download DEQ Form 110-303 "Lead-based Paint Certification" - Oklahoma

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AIR QUALITY DIVISION
LEAD–BASED PAINT CERTIFICATION
Application for Firms
To obtain certification from the Oklahoma Department of Environmental Quality,
1) Type of application? (
)
Initial Firm
(100178)
Renewal Firm
(100181)
Pick only one
2) Firm Name
Responsible Official
Title
Firm Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
Company webpage (if applicable)
3) Lead-Based Paint Services Manager information:
Name
Last
First
Middle
Title
Employer Name
(If different from above Firm.)
Business Address
(If different from above Firm.)
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
4) FEES FOR APPLICATION: Attach a check or money order to this application made payable to: Department of
Environmental Quality. Retain a copy of this application to serve as your receipt/invoice.
Fee Schedule (Do not remit fee if claiming exemption.)
For DEQ Use Only
Fee
Total
Received By
Amount Received
Initial Firm
(100178)
$50.00
Renewal Firm
(100181)
$50.00
STATEMENT OF UNDERSTANDING:
I hereby certify under penalty of law that this application and any attachments contain neither willful nor negligent misrepresentation or
falsification and that all information is true, accurate, and complete. I understand that any misrepresentation or falsification may result in
rejection of my application or in revocation of any certificate issued as a result of this application. I certify that as a Certified Lead-Based
Paint Firm I will comply with all requirements established in OAC 252:110.
SIGNATURE OF RESPONSIBLE OFFICIAL
DATE
PLEASE RETURN APPLICATION TO:
Department of Environmental Quality
Administrative Services Division
P.O. Box 2036
Oklahoma City, OK 73101 (405) 702-4100
Please complete the affidavit on page 2.
DEQ Form #110-303
Revision 10/26/15
AIR QUALITY DIVISION
LEAD–BASED PAINT CERTIFICATION
Application for Firms
To obtain certification from the Oklahoma Department of Environmental Quality,
1) Type of application? (
)
Initial Firm
(100178)
Renewal Firm
(100181)
Pick only one
2) Firm Name
Responsible Official
Title
Firm Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
Company webpage (if applicable)
3) Lead-Based Paint Services Manager information:
Name
Last
First
Middle
Title
Employer Name
(If different from above Firm.)
Business Address
(If different from above Firm.)
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
4) FEES FOR APPLICATION: Attach a check or money order to this application made payable to: Department of
Environmental Quality. Retain a copy of this application to serve as your receipt/invoice.
Fee Schedule (Do not remit fee if claiming exemption.)
For DEQ Use Only
Fee
Total
Received By
Amount Received
Initial Firm
(100178)
$50.00
Renewal Firm
(100181)
$50.00
STATEMENT OF UNDERSTANDING:
I hereby certify under penalty of law that this application and any attachments contain neither willful nor negligent misrepresentation or
falsification and that all information is true, accurate, and complete. I understand that any misrepresentation or falsification may result in
rejection of my application or in revocation of any certificate issued as a result of this application. I certify that as a Certified Lead-Based
Paint Firm I will comply with all requirements established in OAC 252:110.
SIGNATURE OF RESPONSIBLE OFFICIAL
DATE
PLEASE RETURN APPLICATION TO:
Department of Environmental Quality
Administrative Services Division
P.O. Box 2036
Oklahoma City, OK 73101 (405) 702-4100
Please complete the affidavit on page 2.
DEQ Form #110-303
Revision 10/26/15
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
STATE OF OKLAHOMA
)
)
ss.
COUNTY OF OKLAHOMA
)
AFFIDAVIT
I, _______________________________________, being an appointed responsible official of firm applicant, of
lawful age, being first duly sworn, upon oath deposes and states as follows:
1.
That I represent a firm which is an applicant for Firm certification pursuant to OAC 252:110;
2.
That any and all employees and/or subcontractors performing LBP services for the applicant will be
certified by the DEQ prior to such performance;
3.
That the firm and employees or subcontractors thereof will perform LBP services and maintain records
thereof in accordance with all applicable local, state and federal standards;
4.
That the firm
will or
will not obtain and maintain the required level of insurance and bonding
required by the terms of each LBP agreement and/or contract for each specific project.
5.
That the firm
is or
is not applying for an exemption from certification fees as mandated by 27A
O.S.§2-12-201(D)(3). (Further documentation may be required. If applying for exemption, DO NOT
SEND FEE.)
FURTHER AFFIANT SAITH NOT.
______________________________________
APPLICANT/AFFIANT
Subscribed and sworn to before me this _______ day of _________________________, 20____.
______________________________________
NOTARY PUBLIC
My Commission Expires:
___________________
(seal)
DEQ Form #110-303
Revision 10/26/15
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