Free 50745.pdf - Indiana

APPLICATION CHECKSHEET FOR LEAD CONTRACTOR
State Form 50745 (R4 / 2-08)

INDIANA STATE DEPARTMENT OF HEALTH INSTRUCTIONS: 1. 2. DO NOT RETURN THIS SHEET WITH APPLICATION This checklist is used by ISDH to review your Form 48739 "Application for Lead Contractor License" and is provided only to assist you in compiling a complete Standard Operating Procedures manual for submittal with the lead contractor license application.

INDIANA STATE DEPARTMENT OF HEALTH Lead and Healthy Homes Program 2 N Meridian St, 5 J Indianapolis, IN 46204 Phone: (317) 233-1250

http://www.in.gov/isdh/programs/lead/

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FOR OFFICE USE ONLY BY REVIEWER Company name: Applicant name: Designated Representative Name: Reviewed by: Date reviewed: TYPE OF LICENSE NEW LICENSE STATUS APPROVED DENIED PENDING ADDITIONAL INFORMATION PART A: CHECKLIST - GENERAL INFORMATION Has the contractor satisfied the following general requirements?: YES NO RULE
326 IAC 23-2-4(b)(4) 326 IAC 23-2-4(b)(12) 326 IAC 23-2-4(b)(1) If no, provide the following:___________________________________________________________ Proof of financial responsibility attached Verified: ______________________________________________________________________ Indiana Project Supervisor License Submitted copy of current Indiana lead-based paint Project Supervisor license Standard Operating Procedures (SOP) Manual Copy of contractor's written standard operating procedures for the following regulatory programs: 326 IAC 1-1; 326 IAC 23-1; 326 IAC 23-4-11; 29 CFR 1926.62; and 29 CFR 1910.134 NOTE: SOP manual should include detailed, specific written procedures for contractor's compliance with Indiana's lead laws. This includes notification, work practice, and licensing requirements.

LICENSE RENEWAL - Expiration Date: ______/______/______

REQUIREMENT
General and personal information provided

326 IAC 23-2(4)(b)(7)

PART B: CHECKLIST - 326 IAC 23-4
Has the contractor satisfied the following requirements to comply with 326 IAC 23-4?

YES

NO

RULE

REQUIREMENT
Applicability of Rule NOTE:

326 IAC 23-4-1(a) & (b)

Any person or company performing lead-based paint activities shall comply with the appropriate work practices. A political subdivision or a state agency may not accept a bid for a lead-based paint activities project.

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50745 (R4 / 2-08)

Application Checksheet For Lead Contractor 2/08

PART B: CHECKLIST - 326 IAC 23-4 (continued)
Has the contractor satisfied the following requirements to comply with 326 IAC 23-4?

YES

NO

RULE
326 IAC 23-1-3, 7, & 63 326 IAC 23-4-6

REQUIREMENT
Definitions (adequate quality control, child-occupied facility, target housing) Indiana notification requirements/contents/schedule/form Lead abatement procedures - interior
Post warning signs Wall to wall carpeting Wrapped with six (6) mil polyethylene Area shall be sealed from non-work areas After sealing off the work area, floors shall be covered, Forced-air heating and air conditioning systems shall be shut down, Alternative entrances and egresses that are located outside of the work area, Work area shall be cleaned with HEPA vacuum

326 IAC 23-4-7(1) - (8)

Lead abatement procedures - exterior 326 IAC 23-4-8(1) - (3)
Uncontained water, and abrasive blasting Before abating lead paint using wet methods on exterior work areas, the following site preparation procedures shall be used: 23-4-8(2)(A-E) Before beginning to abate lead paint using dry methods on exterior work areas, the following site preparation procedures shall be used: 23-4-8(3)(A-D)

326 IAC 23-4-15 326 IAC 23-4-9(1) - (6)

Notification fees Post-abatement clearance procedures Lead-based paint sampling procedures Clearance sampling under section 9 of this rule shall be conducted as follows:

326 IAC 23-4-10(1) - (4)

Dwelling will be selected for the random sample Dwellings are selected for dust sampling. A licensed supervisor or project designer shall prepare a report; the report shall include (A)-(F).

PART C: CHECKLIST - 326 IAC 23-4-11; 29 CFR 1926.62 and 1910.134
Has the contractor satisfied the following requirements to comply with 326 IAC 23-4-11?

YES

NO

RULE
326 IAC 23-4-11(1) - (5)

REQUIREMENT
Lead-based paint abatement disposal procedures Follow these procedures when disposing of lead- based paint waste- (1)-(5) Construction Standard:
Permissible exposure limit Regulated areas Exposure monitoring Engineering controls & work practices Respiratory protection Protective clothing Clean change areas Hazard communications to employees Medical surveillance

29 CFR 1926.62

29 CFR 1910.134

Respiratory Protection Standards

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INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50745 (R4 / 2-08)

Application Checksheet For Lead Contractor 2/08

PART D: CHECKLIST - 326 IAC 23-2-4(b)
Has the contractor satisfied the following requirements to comply with 326 IAC 23-2-4(b)?:

YES

NO

RULE
326 IAC 23-2-4(b)(4)

REQUIREMENT
Competency Demonstrated competency in the field of lead project implementation and has read and understands 326 IAC 23 and 40 CFR 745. Prior Contracts A complete list of prior contracts for the previous 36 months for lead projects including names, addresses & telephone numbers of persons for whom projects were performed Terminated Lead Projects A description of any lead-based paint projects which were prematurely terminated or not completed, including circumstances surrounding termination Contractual Penalties A list of any contractual penalties related to lead-based paint activities that contractor has paid for noncompliance with contract specifications Citations/Violations/Findings Copies of any and all citations, notices of violation, or findings of violation levied against the contractor for violations of regulations pertaining to lead abatement and a description of how the allegations were resolved Legal Actions/Claims A description detailing all legal proceedings, lawsuits or claims levied against the contractor or any of his/her past or present employees while employed by the contractor, for lead-based paint related activities

326 IAC 23-2-4(b)(6)

326 IAC 23-2-4(b)(8)

326 IAC 23-2-4(b)(9)

326 IAC 23-2-4(b)(10)

326 IAC 23-2-4(b)(11)

PART E: CHECKLIST - OTHER
Are the following items included with contractor application?

YES

NO

RULE
326 IAC 23-2-4(b)(1) 326 IAC 23-2-4(e) 326 IAC 23-2-4(b)(2) 326 IAC 23-2-8

REQUIREMENT
White colored lead signature cards signed and attached Two 1-½ inch by 1-½ inch recent color photographs of applicant attached Application signed Application fee of $150 submitted with application

ART F: REVIEWER'S COMMENTS

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