Application Checksheet For Lead Contractor {50745}

APPLICATION CHECKSHEET FOR LEAD CONTRACTOR State Form 50745 (R6 / 4-11) 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. FOR OFFICE USE ONLY BY REVIEWER Company name: Applicant name: Designated Representative Name: Reviewed by: Date reviewed (month, day, year): 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 410 IAC 32-2-4(b)(4) 410 IAC 32-2-4(b)(12) 410 IAC 32-2-4(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: 410 IAC 32-1; 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 410 IAC 32-2(4)(b)(7) PART B: CHECKLIST - 410 IAC 32-4 Has the contractor satisfied the following requirements to comply with 410 IAC 32-4? YES NO RULE REQUIREMENT Applicability of Rule NOTE: 410 IAC 32-4-1(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. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50745 (R6 / 4-11) Application Check sheet For Lead Contractor 4/11 PART B: CHECKLIST - 410 IAC 32-4 (continued) Has the contractor satisfied the following requirements to comply with 410 IAC 32-4? YES NO RULE 410 IAC 32-1-3, 9, & 78 410 IAC 32-4-6 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 410 IAC 32-4-7(1) - (8) Lead abatement procedures - exterior 410 IAC 32-4-8(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: 32-4-8(2)(A-E) Before beginning to abate lead paint using dry methods on exterior work areas, the following site preparation procedures shall be used: 32-4-8(3)(A-D) 410 IAC 32-4-15 410 IAC 32-4-9(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: 410 IAC 32-4-10(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 - 410 IAC 32-4-11; 29 CFR 1926.62 and 1910.134 Has the contractor satisfied the following requirements to comply with 410 IAC 32-4-11? YES NO RULE 410 IAC 32-4-11(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 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com INDIANA STATE DEPARTMENT OF HEALTH LEAD AND HEALTHY HOMES PROGRAM State Form 50745 (R6 / 4-11) Application Check sheet For Lead Contractor 4/11 PART D: CHECKLIST - 410 IAC 32-2-4(b) Has the contractor satisfied the following requirements to comply with 410 IAC 32-2-4(b)?: YES NO RULE 410 IAC 32-2-4(b)(4) REQUIREMENT Competency Demonstrated competency in the field of lead project implementation and has read and understands 410 IAC 32 and 40 CFR 745. Prior Contracts A complete list of prior contracts for the previous thirty-six (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 410 IAC 32-2-4(b)(6) 410 IAC 32-2-4(b)(8) 410 IAC 32-2-4(b)(9) 410 IAC 32-2-4(b)(10) 410 IAC 32-2-4(b)(11) PART E: CHECKLIST - OTHER Are the following items included with contractor application? YES NO RULE 410 IAC 23-2-4(b)(3) 410 IAC 32-2-4(e) 410 IAC 32-2-4(b)(2) 410 IAC 32-2-9 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 sub