(Rev



ASBESTOS ACCREDITATION AFFADAVIT (AAC-1)

Louisiana Department of Environmental Quality

Office of Environmental Services

Public Participation and Permit Support Division

Notifications and Accreditations Section

P.O. Box 4313, Baton Rouge, LA 70821-4313

Physical Address: 602 N. 5th St, BR, LA 70802

Phone (225) 219-3250

(This form must be received by mail or hand-delivered. No faxed applications will be processed.)

I. Applicant Information (Print legibly or type) EMERGENCY: YES NO (Explanations of fees are noted in Section III.)

| Name | |Accreditation Renewal | Yes No |

| Has status as a Registered Architect, Engineer, or CIH changed? | Yes No | Date of Birth | |

| Driver’s License/State ID No. | | Issuing State of Driver’s License/State ID | Louisiana Other__________________ |

| |

| Company | | Phone no. |( ) |

| Address | | | |

| City | |

II. Check Accreditations Desired Complete one application only for one or more disciplines.

Worker Contractor/Supervisor Inspector Management Planner Project Designer

Fees Workers: Normal Processing: $ 73 Emergency: $ 109

All Others (per Discipline): Normal Processing: $ 291 Emergency: $ 436

(Emergency applications are processed in approximately 5 working days)

FEES ARE NON-TRANSFERABLE / NON-REFUNDABLE–No Cash Accepted (Check or Money Order Only, Payable to LDEQ)

III. Qualifications for Accreditations

|1. Attach copy of initial and all refreshers for first time applicants. Originals will not be returned. Renewals attach applicable refresher training(s). |

|2. If training not received from a Louisiana recognized training provider, provide proof of La. 2-hr regulations per LAC 33:III.Chapters 27 & 51. |

|3. Attach full face picture for each accreditation desired - Cut EXACTLY 1” X 1 ¼” & labeled with applicant’s name on back. |

|4. Inspectors (first time only) submit copy of high school diploma or highest level of education received, the minimum being a GED. |

|5. Management Planners (first time only) provide proof as Registered Architect, Engineer, CIH, or related scientific field. |

|6. Project Designers (first time only) provide proof as Registered Architect, Engineer, or CIH. |

IV. Regulation Knowledge and Enforceability

|I have an updated copy of the Louisiana Administrative Code, Title 33, Part III. Chapters 27 and 51.Subchapter M, including the revisions, which pertain to Asbestos |

|regulations. I have read and understand the Louisiana regulations. I am aware that in accordance with La. R.S. 30:2025.F.2, any person who knowingly and intentionally|

|makes any false statement, representation or certification in any document filed or required to be maintained, shall upon conviction be punished by a fine of not more |

|than twenty-five thousand dollars ($25,000) or imprisonment for not more than 1 year, or both. In addition, I understand that, under Privacy Act 5 USC 552(a), my |

|personal information is being given voluntarily and may be used by the Louisiana Department of Environmental Quality to verify my identity. |

| |

|Applicant’s Signature ____________________________________________ Date: _______________________ |

V. Validity of Accreditation

Note: Continuous accreditation will be maintained with the same annual expiration/renewal date provided you submit the required documents and receive refresher training within 90 days prior to your expiration/renewal date.

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|For LDEQ Use Only |

|Ck. No. |M.O. No. |

|Date |Amt. |

| |$ |

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