DEQ Form 110-101 "Lead-Based Paint (Lbp) and Renovation, Repair and Painting (Rrp) Training Program Accreditation Application" - Oklahoma

What Is DEQ Form 110-101?

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 July 30, 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 110-101 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 110-101 "Lead-Based Paint (Lbp) and Renovation, Repair and Painting (Rrp) Training Program Accreditation Application" - Oklahoma

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DEPARTMENT OF ENVIRONMENTAL QUALITY
AIR QUALITY DIVISION
LEAD-BASED PAINT (LBP) AND
RENOVATION, REPAIR AND PAINTING (RRP)
TRAINING PROGRAM ACCREDITATION APPLICATION
1) Program Name
Mailing Address
City
State
Zip
County
Street Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
Driving Directions
2) As per OAC 252:100-9-19(b) is your facility an educational institution or government agency?
YES
NO
3) *Do you wish to use accreditation from another state/agency for recognition and approval?
YES
NO
State/Agency:
(If yes, then please provide documentation for Equivalency Review.)
4) Does the training program use EPA-developed model training materials?
YES
NO
(If no, then please include a copy of the training materials that will be used.)
5) Training Manager
Social Security #
/
/
Mailing Address
City
State
Zip
County
Street Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
6) Instructor Name
Social Security #
/
/
Last
First
Middle
Employer
Business Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
7) Instructor for:
LBP Inspector
(100185)
LBP Risk Assessor
(100186)
LBP
Supervisor(100187)
LBP Abatement Worker
RRP Renovator
RRP Dust Sampling Technician
(Note: Instructors of Inspector, Risk Assessor and Supervisor courses will need to take and pass the EPA exam every three
years and pay the corresponding Principle Instructor Exam Fee(s).)
DEQ Form #110-101
Page 1 of 2
Revised 7/30/2013
DEPARTMENT OF ENVIRONMENTAL QUALITY
AIR QUALITY DIVISION
LEAD-BASED PAINT (LBP) AND
RENOVATION, REPAIR AND PAINTING (RRP)
TRAINING PROGRAM ACCREDITATION APPLICATION
1) Program Name
Mailing Address
City
State
Zip
County
Street Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
Driving Directions
2) As per OAC 252:100-9-19(b) is your facility an educational institution or government agency?
YES
NO
3) *Do you wish to use accreditation from another state/agency for recognition and approval?
YES
NO
State/Agency:
(If yes, then please provide documentation for Equivalency Review.)
4) Does the training program use EPA-developed model training materials?
YES
NO
(If no, then please include a copy of the training materials that will be used.)
5) Training Manager
Social Security #
/
/
Mailing Address
City
State
Zip
County
Street Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
6) Instructor Name
Social Security #
/
/
Last
First
Middle
Employer
Business Address
City
State
Zip
County
Phone (
)
Fax (
)
E-mail
7) Instructor for:
LBP Inspector
(100185)
LBP Risk Assessor
(100186)
LBP
Supervisor(100187)
LBP Abatement Worker
RRP Renovator
RRP Dust Sampling Technician
(Note: Instructors of Inspector, Risk Assessor and Supervisor courses will need to take and pass the EPA exam every three
years and pay the corresponding Principle Instructor Exam Fee(s).)
DEQ Form #110-101
Page 1 of 2
Revised 7/30/2013
8) Please complete the following Fee Schedule for application:
Attach a check or money order to this application made payable to: Department of Environmental Quality
Fee Schedule
Initial Only
Renewal Only
Type of Discipline
Filing, Review, & Accreditation Fee
Filing, Review, & Accreditation Fee
SubTotal
Inspector
$450.00
$250.00
(100791)
(100801)
Refresher Inspector
$450.00
$250.00
(100792)
(100802)
Risk Assessor
$450.00
$250.00
(100793)
(100803)
Refresher Risk Assessor
$450.00
$250.00
(100794)
(100804)
Supervisor
$450.00
$250.00
(100795)
(100805)
Refresher Supervisor
$450.00
$250.00
(100796)
(100806)
Project Designer
$450.00
$250.00
(100797)
(100807)
Refresher Designer
$450.00
$250.00
(100798)
(100808)
Abatement Worker
$450.00
$250.00
(100799)
(100809)
Refresher Worker
$450.00
$250.00
(100800)
(100810)
Renovator
$140.00
$85.00
(101164)
(101168)
Refresher Renovator
$100.00
$77.50
(101166)
(101170)
Dust Sampling Technician
$140.00
$85.00
(101165)
(101169)
Refresher Dust Sampling
$100.00
$77.50
(101167)
(101171)
Technician
Training Manager Fee
$100.00
$50.00
(100811)
(100812)
Principle Instructor Fee (each)
$50.00
$25.00
(100813)
X __ Instructors
(100814)
X __Instructors
*Equivalency Review
$2250.00
(
$1125.00
100815)
(100816)
$50.00
X __ Inspector Exam+
(100185)
Principle Instructor Exam Fee
$50.00
X __ Risk Assessor Exam+
(100186)
$50.00
X __ Supervisor Exam
(100187)
Late Fee
$750.00
(100817)
Total
(DEQ Use Only) Total Received by DEQ
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 accreditation issued as a result of this application. I certify that the Training Program meets the minimum
requirements established in OAC 252:110, Lead-Based Paint Management, and that each Principle Instructor and Work-Practice Instructor meets
the required qualifications prior to teaching any approved course.
SIGNATURE OF TRAINING MANAGER
DATE
PLEASE RETURN APPLICATION TO:
Department of Environmental Quality
Financial & Human Resources Management
P. O. Box 2036
Oklahoma City, OK 73101
(405) 702-4100
DEQ Form #110-101
Page 2 of 2
Revised 7/30/2013
To avoid having the accreditation application process delayed due to insufficient information, please complete
the following checklist:
Did you:
Include a copy of an EPA or state approval letter for each course previously approved by the
EPA or another state?
Include documentation of accreditation as a LBP training program issued by another state or
entity (if applicable)?
Include a description of the campus, student-instructor ratios, number of course offerings, and
estimated enrollment?
Include a list of training equipment and materials acquired or proposed for acquisition?
Include an outline of curriculum requirements for each course including classroom instruction
elements, hands-on instruction elements, and time allotted?
Include a copy of all course materials – including handouts?
Include a test blueprint and copy of exams to be given with a detailed statement about the
development of the course tests?
Include details on the hands-on skills assessment?
Include minimum competency and proficiency requirements?
Include a quality control plan?
Include a copy of student and instructor manuals to be used for each course, and a copy of the
course agenda for each course (only if your program does not use EPA developed model
training materials?
Include the appropriate documentation for the instructors and the training manager?
Include copies or samples of advertising materials (current or proposed)?
Include a student attendance plan?
Include a copy of the proposed course completion certificate?
Include all relevant application fees?
Sign and date the statement of understanding?
DEQ Form #110-101
Checklist
Revised 7/30/2013
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