DEQ Form 110-122 "Notification of Lead-Based Paint Course Completion" - Oklahoma

What Is DEQ Form 110-122?

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 110-122 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 110-122 "Notification of Lead-Based Paint Course Completion" - Oklahoma

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Notification of Lead-Based Paint Course Completion
This form must be completed and submitted a minimum of 10 business days following completion
of any Lead-Based Paint or Renovator course in order to comply with the notification
requirements of OAC 252:110-5-1.
Training Provider Information
(
)
Accredited Training Provider
Accreditation #
Telephone #
Training Provider Address
City
State
Zip
LBP Course Information
Course Type (mark one):
Initial
Refresher
Course Discipline (mark one): Inspector
Risk Assessor
Supervisor
Abatement Worker
Renovator
Training Start Date:
Training Stop Date:
Student Information
1.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
2.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
3.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
4.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
5.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
6.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
7.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
8.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
9.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
DEQ Form # 110-122
Revised 5/21/13
Notification of Lead-Based Paint Course Completion
This form must be completed and submitted a minimum of 10 business days following completion
of any Lead-Based Paint or Renovator course in order to comply with the notification
requirements of OAC 252:110-5-1.
Training Provider Information
(
)
Accredited Training Provider
Accreditation #
Telephone #
Training Provider Address
City
State
Zip
LBP Course Information
Course Type (mark one):
Initial
Refresher
Course Discipline (mark one): Inspector
Risk Assessor
Supervisor
Abatement Worker
Renovator
Training Start Date:
Training Stop Date:
Student Information
1.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
2.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
3.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
4.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
5.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
6.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
7.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
8.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
9.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
DEQ Form # 110-122
Revised 5/21/13
10.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
11.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
12.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
13.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
14.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
15.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
16.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
17.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
18.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
19.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
20.
Name:
Street Address:
City:
State:
Zip Code:
Date of Birth:
Certificate Number:
Test Score:
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 or Renovator certification as well as civil and/or criminal
sanctions.
Training Manager’s Name (printed)
Signature
Date
Title
*A photo of each student is required for Renovator and Dust Sampling Technician courses.
Please see www.epa.gov/lead/pubs/trainerinstructions.htm for photo specifications. The photos should be sent in a digital format along with this form.
DEQ Office Use Only
Date Rec’d:
Notification #:
DEQ Form # 110-122
Revised 5/21/13
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