DEQ Form 110-301 "Lead-Based Paint Certification Application" - Oklahoma

What Is DEQ Form 110-301?

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 1, 2019;
  • 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 fillable version of DEQ Form 110-301 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 110-301 "Lead-Based Paint Certification Application" - Oklahoma

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LEAD–BASED PAINT CERTIFICATION
APPLICATION
Air Quality Division
Initial Inspector
(100188)
Renewal Inspector
(100197)
Reinstated Inspector
(100188)
Initial Inspector/Risk Assessor
(100189)
Renewal Inspector/Risk Assessor
(100198)
Reinstated Inspector/Risk Assessor
(100189)
Initial Supervisor
(100192)
Renewal Supervisor
(100199)
Reinstated Supervisor
(100192)
Initial Project Designer
(100194)
Renewal Project Designer
(100200)
Reinstated Project Designer
(100194)
Initial Abatement Worker
(100196)
Renewal Abatement Worker
(100201)
Reinstated Abatement Worker
(100196)
First time applicants check only one initial discipline per application. Affidavits of citizenship are only submitted once. If testing
is required, you will be contacted to schedule the exam once the application is complete. Renewal applicants may submit all
individual certifications on one application, including fees. Exempt entities do not pay exam fees.
1) When do you want your certification to be activated? (This is for initial applicants only)
Immediately
Next Full Year
(Present date through following March 31)
(April 1 through March 31)
2) Name
Social Security #
/
/
Last
First
Middle
Firm Name
Firm Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
3) Permanent Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
4) TRAINING CREDIT: Check the Lead-Based Paint Training classes you have recently attended. Attach a copy of
each training class completion certificate for each discipline for which you are applying.
Initial Inspector (24hrs)
Inspector Refresher (8 hrs)
Initial Risk Assessor (16 hrs)
Risk Assessor Refresher (8 hrs)
Initial Supervisor (32 hrs)
Supervisor Refresher (8 hrs)
Initial Project Designer (40 hrs)
Project Designer Refresher (8 hrs)
Initial Abatement Worker (16 hrs)
Abatement Worker Refresher (8 hrs)
DEQ OFFICE USE ONLY
Date AQD Received
By
(AR) Amount Received
By
Date
Certification #
(HR) Affidavit of Citizenship
Denied By
Date
Abatement Worker
$30
(100196)
Renewal Abatement Worker
$15
(100201)
Reinstated Abatement Worker
$30
(100196)
Project Designer
$500
(100194)
Renewal Project Designer
$250
(100200)
Reinstated Project Designer
$500
(100194)
Inspector
$200
(100188)
Renewal Inspector
$100
(100197)
Reinstated Inspector
$200
(100188)
Risk Assessor
$300
(100189)
Renewal Risk Assessor
$150
(100198)
Reinstated Risk Assessor
$300
(100189)
Supervisor
$150
(100192)
Renewal Supervisor
$75
(100199)
Reinstated Supervisor
$150
(100192)
Equivalency Review
$500
(100718)
Exam Fee
$50
(100190)
No Fees Received
$0
Exam Fee
$50
(100191)
(HR STAMP)
Exam Fee
$50
(100193)
DEQ Form #110-301
1
Revised 5/1/19
LEAD–BASED PAINT CERTIFICATION
APPLICATION
Air Quality Division
Initial Inspector
(100188)
Renewal Inspector
(100197)
Reinstated Inspector
(100188)
Initial Inspector/Risk Assessor
(100189)
Renewal Inspector/Risk Assessor
(100198)
Reinstated Inspector/Risk Assessor
(100189)
Initial Supervisor
(100192)
Renewal Supervisor
(100199)
Reinstated Supervisor
(100192)
Initial Project Designer
(100194)
Renewal Project Designer
(100200)
Reinstated Project Designer
(100194)
Initial Abatement Worker
(100196)
Renewal Abatement Worker
(100201)
Reinstated Abatement Worker
(100196)
First time applicants check only one initial discipline per application. Affidavits of citizenship are only submitted once. If testing
is required, you will be contacted to schedule the exam once the application is complete. Renewal applicants may submit all
individual certifications on one application, including fees. Exempt entities do not pay exam fees.
1) When do you want your certification to be activated? (This is for initial applicants only)
Immediately
Next Full Year
(Present date through following March 31)
(April 1 through March 31)
2) Name
Social Security #
/
/
Last
First
Middle
Firm Name
Firm Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
3) Permanent Address
City
State
Zip
County
Phone # (
)
Fax # (
)
E-mail
4) TRAINING CREDIT: Check the Lead-Based Paint Training classes you have recently attended. Attach a copy of
each training class completion certificate for each discipline for which you are applying.
Initial Inspector (24hrs)
Inspector Refresher (8 hrs)
Initial Risk Assessor (16 hrs)
Risk Assessor Refresher (8 hrs)
Initial Supervisor (32 hrs)
Supervisor Refresher (8 hrs)
Initial Project Designer (40 hrs)
Project Designer Refresher (8 hrs)
Initial Abatement Worker (16 hrs)
Abatement Worker Refresher (8 hrs)
DEQ OFFICE USE ONLY
Date AQD Received
By
(AR) Amount Received
By
Date
Certification #
(HR) Affidavit of Citizenship
Denied By
Date
Abatement Worker
$30
(100196)
Renewal Abatement Worker
$15
(100201)
Reinstated Abatement Worker
$30
(100196)
Project Designer
$500
(100194)
Renewal Project Designer
$250
(100200)
Reinstated Project Designer
$500
(100194)
Inspector
$200
(100188)
Renewal Inspector
$100
(100197)
Reinstated Inspector
$200
(100188)
Risk Assessor
$300
(100189)
Renewal Risk Assessor
$150
(100198)
Reinstated Risk Assessor
$300
(100189)
Supervisor
$150
(100192)
Renewal Supervisor
$75
(100199)
Reinstated Supervisor
$150
(100192)
Equivalency Review
$500
(100718)
Exam Fee
$50
(100190)
No Fees Received
$0
Exam Fee
$50
(100191)
(HR STAMP)
Exam Fee
$50
(100193)
DEQ Form #110-301
1
Revised 5/1/19
5) EXPERIENCE: List your applicable experience (252:110-5-1(3)). List your present job first. Attach additional sheets
or resume with references if needed.
Job Title
From
/
To
/
Month/Year
Month/Year
Employer Name
Employer Address
City
State
Zip
County
Phone # (
)
Fax # (
)
Supervisor
Describe your duties:
6) EDUCATION: List your highest level of education. Attach documentation (copy of diploma or transcript) if applying
for Risk Assessor or Project Designer discipline.
Degree
Institution
7) *Do you wish to use certification from another state or agency for application?
YES
NO
8) PLEASE CHECK () ALL APPROPRIATE FEES FOR APPLICATION:
Certification fees must be paid before application can be processed by DEQ. Attach (do not staple) a check or money
order to this application made payable to:
Oklahoma Department of Environmental Quality
9) If paying via credit card please give DEQ’s accounting department the following information:
Name of contact person
Phone # (
)
Fee Schedule
Initial and Reinstatement
Renewal Only
Type of Discipline
Discipline Fee
Exam Fee
Discipline Fee
Extended Total
(Select one discipline)
(Must select Exam Fee)
Inspector
$200.00
$50.00
$100.00
Inspector/ Risk Assessor
$300.00
$50.00
$150.00
Supervisor
$150.00
$50.00
$75.00
Project Designer
$500.00
N/A
$250.00
Abatement Worker
$30.00
$15.00
N/A
*Equivalency Review (Select if you marked ‘yes’ to question no. 8)
$500.00
TOTAL
Check here to claim exemption from certification and exam fees
Note: A
pplicants claiming exemption must enclose a completed government affidavit form (DEQ Form #110-304) with this application.
DEQ Form #110-301
2
Revised 5/1/19
OKLAHOMA DEPARTMENT OF ENVIRONMENTAL QUALITY
STATE OF OKLAHOMA
)
)
ss.
COUNTY OF OKLAHOMA
)
AFFIDAVIT
I, _______________________________________, of lawful age, being first duly sworn, upon oath depose and
state as follows:
1.
That I am an applicant for inspector, risk assessor, supervisor, project designer, or abatement worker
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 applicant 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 applicant will only perform LBP services for DEQ certified firms;
That the applicant ☐ will or ☐ will not obtain and maintain the required level of insurance and bonding
5.
required by the terms of each LBP agreement and/or contract for each specific project.
6.
If applying for reinstatement, the applicant swears under a penalty of perjury, that lead-based paint services
have not been performed during the time applicant was not certified with the Department of Environmental
Quality.
FURTHER AFFIANT SAITH NOT.
______________________________________
APPLICANT/AFFIANT
Subscribed and sworn to before me this
day of
, 20
______________________________________
NOTARY PUBLIC
My Commission Expires:
___________________
(seal)
DEQ Form #110-301
3
Revised 5/1/19
To avoid certification application delays due to insufficient information, please complete the following checklist.
Did You...
1.
include a notarized affidavit of citizenship (if an initial applicant)?
2.
sign and date the application and sign and notarize affidavit(s)?
3.
indicate name, permanent mailing address, email address and telephone number?
4.
indicate the name, mailing address and the telephone/fax numbers of your company?
5.
include a copy of training certificate received from accredited training provider?
6.
include documentation of education (if applicable)?
7.
include dates of experience such as a resume or letter of reference (if applicable)?
8.
include all relevant application fees?
9.
include contact information for out of state training provider (if applying for equivalency
review)?
10.
include a signed government affidavit form #110-304 (if applying for exemption from
certification fees)?
STATEMENT OF UNDERSTANDING:
I hereby certify under penalty of law that this application and any attachments contain neither willful nor negligent misrepresentation nor
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 revocation of any certificate issued as a result of this application. I certify that as a Certified Lead-Based
Paint Contractor, I will comply with all requirements established in OAC 252:110.
SIGNATURE OF APPLICANT
DATE
PLEASE RETURN APPLICATION TO:
Department of Environmental Quality
Administrative Services Division
P.O. Box 2036
Oklahoma City, OK 73101
(405) 702-4100
DEQ Form #110-301
4
Revised 5/1/19
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