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HomeMy WebLinkAboutLead-Based Paint activitiesRESOLUTION 2012-204 ADOPTED DOC ID: 7642 THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2012-204 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON FEBRUARY 28, 2012: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisor Scott A. Russell to execute the U.S. Environmental Protection A~,encv Form 8500-27 entitled "Application for Firms to Conduct Lead-Based Paint Activities and/or Renovations" for the Town to obtain an EPA certification to conduct said activities and further authorizes the application fee payment in the sum of $300.00 to the EPA (A.1620.4.600.700), subject to the approval of the Town Attorney. Elizabeth A. Neville Southold Town Clerk RESULT: ADOPTED [UNANIMOUS] MOVER: Jill Doherty, Councilwoman SECONDER: William Ruland, Councilman AYES: Ruland, Talbot, Doherty, Krupski Jr., Evans, Russell EPA APPLICATION FOR FIRMS U.S. ENVIRONMENTAL PROTECTION AGENCY TO CONDUCT LEAD-BASED PAINT ACTIVITIES AND/OR RENOVATIONS Important: This application is required by 40 CFR §745.89(a) for renovations and is a substitute for the letter required by §745.226(f)(2) for abatement. Consult the instructions for firms applying for certification to conduct lead-based activities or renovations. For abatement activities, persons seeking individual certification should use the Application for Individuals instead of this form. Please fill out all sections. Type or print responses In black or blue Ink only. A. Application Type (select only one box from Option 1, 2, 3 or 4 of Section A) 1. I Option 1: Renovation. Reoair. and Paintinq (RRP and Dust Samplinq Technician) Firm Certification / Initial Recertification e~ or ~..~ Renovation, Repair and Painting Firm Certification ($300) o.~r Option 2: Abatement (Abatement. Risk Assessment, and Inspection) or Abatement/RRP Combination Firm Certification Initial Recertification (~) or O Abatement Firm Certification ($550 for firet jurisdiction and $35 for each additional jurisdiction - list jurisdiction(s) below) Initial Recertification © or © Combination Abatement/RRP Firm Certification ($550 for RRP and one abatement jurisdiction, $35 for each additional abatement jurisdiction - list abatement jurisdiction(s) below) List abatement jurisdiction(s): 1) ($550) 2) ($585) 3) ($620) (Please note, if applying for more than three jurisdictions add an additional $35 for each judsdictien and list them on a separate sheet of paper) 3: Amend Existina Certification Update firm information (no fee required) o~r Add abatement jurisdiction ($35 per abatement jurisdiction) List abatement jurisdiction(s) being added to your existing certification: 1) ($35) 2) ($70) 3) ($105) o.~r 4. I Option 4: ReDlace Certificate (~) Replace Certificate ($15) Enter total application fee $ 300.00 Note 1: See instructions for additional fee information and examples of required foes. Note 2: If you are a federally recognized Indian Tribe seeking certification as a firm check yes in the question below and see Fees Schedule in the instructions to determine fee required. Yes O No (~) Indicate whether you are a federelly-recognized Indian tdbe seeking certification as a firm. C, Applicant Information Name of Firm: TOWr} of Southold BusinessAddress: 53095 Route 25, P.O. Box 1179 Southold NY 11971-o'/, Street Address, Suite Number (Please no P.O. Box) City State Zip Code Mailing Address: (if differe~ from abo'~) Street Address, Suite Number City State Zip Code Name of Attesting Individual: Russell Scott A. Last Firm's Phone#: (631)765-1889 ext#' Attesting Individual's E-mail Address: First Middle Attesting lndividual's Phone #: (631) 765-1889 ext scott.russell@town.southold.ny.us EPA Form 8500-27 (Rev 9/11 ) Page 1 of 2 Fonm Aplxoved OMB No 2070-0155 Ex. ms 1 D/31/11 D. Website Listing Once certified your firm will be listed on EPA's web based search tool. Please select the type of service(s) your firm will provide: [] Renovation [] Evaluation [] Lead Abatement E. Lead-Based Paint Activity or Renovation Violation[s] Does the firm have any past, present, or pending lead-based paint violations of EPA, Yes (~ No (~ State, U.S. territory, or Indian tribal land(s) regulations? If yes, please attach a written explanation. F. Certification Statement I hereby attest and affirm the following: The information included on this application, including any attachments, is true and accurate to the best of my belief and knowledge. · This firm shall only employ appropriately qualified individuals to conduct lead-based paint activities and renovations. · This firm and its employees shall follow the work practica standards set forth in 40 CFR § 745.227 for conducting lead-based paint activities or 40 CFR § 745.85 for conducting renovations at all times. · I acknowledge that any certification issued pursuant to this application, including any attachments, will be subject to revocation if issuance was based on incorrect or inadequate information that materially affected the decision to issue the certification. Individual's Signature (Please sign legibly wilhin the boundaries of the box above.) Supervisor ~ /,¢ / T~tle Date Signed Pdvacy Act Statement; This statement is provided pursuant to the P~ivacy Act of 1974, 5 U.S.C. §552a. The autho~y for col.:ting this infofrnaiton is 40 C FR. Part 745, and 15 US.C. ~2682 and 2684. The information cctlented on this form will be used to establish the applicant's eligJblllty for certification to conduct lead-based paint activities and renovations in thriver housing and child-occupied facilities. Disclosure of this information is voluntary: however, the failure to provide this information may delay or prevent an applicant's certification. This infom~ation may be disclosed in appropriate and limited circumstances to: EPA employees, contractors, grantees or others when per[orming duties that are cofwpatible with the purpose for which this iofc~mation is c~iected and when this information is necessary to coa3piete the task; a member of Congress in response to a request made with your consent and o~ your beh~f; to appropriate law enforcement agencies responsible for investigating, enforcing, presecuitng or implementing sbe~fic statutes, codes or regulations and this information is relevant to that responsibility; an aaprapdate adjudicative body when such disclosure is compatible with the purpose for which this information is cbllented and the EPA or the United States has an interest in the proceeding: and the Department of the Treasury, the General Se~ces Administration, the General Accounting Oflioe and other Federal, State. and LocaJ Agencies for autndfized activities related to this information. Before you mail your application and certification fee, make sure that you have: · Filled out all applicable sections of the application · Signed and dated the application · Made a copy of your application for your files · Enclosed the appropriate certification fees (check or money order) · Make check payable to U.S. EPA · Pdnted ~Lead Program User Fees" on the check or money order · For more information, see the fees section of the instructions Mail original completed application, supporting materials, and the certification fee to: U.S. EPA Lead User Fees P.Q Box 979072 St. Louis, MO 63197-9000 EPA Form 8500-27 (Rev 9111 ) Page 2 of 2