DEQ Form 110-121 "Notification of Lead-Based Paint Course" - Oklahoma

What Is DEQ Form 110-121?

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 May 21, 2013;
  • 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 110-121 by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Environmental Quality.

ADVERTISEMENT
ADVERTISEMENT

Download DEQ Form 110-121 "Notification of Lead-Based Paint Course" - Oklahoma

1460 times
Rate (4.8 / 5) 88 votes
Notification of Lead-Based Paint Course
This form must be completed and submitted a minimum of 7 business days prior to start of any
Lead-Based Paint or Renovator course in order to comply with the notification requirements of
OAC 252:110-5-1.
Type of notification:
Initial
Amendment
Cancellation
Amendments (complete only if notification is an amendment or cancellation)
Initial Start Date:
Initial Stop Date:
Change Start Date to:
Change Stop Date to:
Please provide a brief explanation for amendment/cancellation
Training Provider Information
(
)
Accredited Training Provider
Accreditation #
Telephone #
Training Provider Address
City
State
Zip
LBP Course Information
Course Type
Initial
Refresher
(mark one):
Course Discipline (
):
Inspector
Risk Assessor
Supervisor
Abatement Worker
Renovator
mark one
Training Start Date
Training Stop Date
:
:
Training Start Time:
Training Stop Time:
(
)
Training Location
Telephone #
Address
City
State
Zip
Principal Instructor
Statement of Understanding
I hereby certify under penalty of law that this notification 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 revocation or suspension of any LBP certification as well as civil and/or criminal sanctions.
Training Manager’s Name (printed)
Signature
Date
Title
DEQ Office Use Only
Date Rec’d
Notification #
DEQ Form # 110-121
Revised 5/21/13
Notification of Lead-Based Paint Course
This form must be completed and submitted a minimum of 7 business days prior to start of any
Lead-Based Paint or Renovator course in order to comply with the notification requirements of
OAC 252:110-5-1.
Type of notification:
Initial
Amendment
Cancellation
Amendments (complete only if notification is an amendment or cancellation)
Initial Start Date:
Initial Stop Date:
Change Start Date to:
Change Stop Date to:
Please provide a brief explanation for amendment/cancellation
Training Provider Information
(
)
Accredited Training Provider
Accreditation #
Telephone #
Training Provider Address
City
State
Zip
LBP Course Information
Course Type
Initial
Refresher
(mark one):
Course Discipline (
):
Inspector
Risk Assessor
Supervisor
Abatement Worker
Renovator
mark one
Training Start Date
Training Stop Date
:
:
Training Start Time:
Training Stop Time:
(
)
Training Location
Telephone #
Address
City
State
Zip
Principal Instructor
Statement of Understanding
I hereby certify under penalty of law that this notification 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 revocation or suspension of any LBP certification as well as civil and/or criminal sanctions.
Training Manager’s Name (printed)
Signature
Date
Title
DEQ Office Use Only
Date Rec’d
Notification #
DEQ Form # 110-121
Revised 5/21/13