ࡱ> LNKq  bjbjt+t+ *DAA ]  8 D2 L b D xzzzzzz$ui(u !!!Y YYY! x !xYY%V,@ x ~ `r( 7"l New Jersey Department of Health Consumer, Environmental and Occupational Health Service Environmental and Occupational Health Assessment Program PO Box 372 Trenton, NJ 08625-0372 Telephone: 609-826-4950 / Fax: 609-826-4975 Request for Reciprocity Verification of Lead Licensure Status with new york state Directions: Applicants using New York State (NYS) certification issued after July, 2014 to apply for a New Jersey lead permit must complete Section I of this form and submit the form to their NYS licensing office for completion. The licensing agency must complete Section II of this form. The completed form can either be faxed or mailed to our office by the licensing agency. Please note: This office will not accept Request for Reciprocity forms submitted directly to us by the applicant. This form must be submitted by licensing agency. Reciprocity applications will not be approved without a completed Request for Reciprocity form. Out-of-state certifications must be currently valid. Fax the completed form to the EPA at 732-321-6757 or call them at 732-321-4374.Section I - TO BE COMPLETED BY APPLICANTName (Last Name, First Name)  FORMTEXT      Out of State ID No. (if applicable)  FORMTEXT      Date of Birth  FORMTEXT      Discipline(s) applying for (check all that apply)  FORMCHECKBOX  Lead Worker for Housing and Public Buildings  FORMCHECKBOX  Lead Inspector/Risk Assessor*  FORMCHECKBOX  Lead Supervisor for Housing and Public Buildings  FORMCHECKBOX  Lead Planner/Project Designer *Applicants must have a currently valid Lead Inspector/Risk Assessor or Lead Risk Assessor certification from another EPAauthorized state in order to be eligible to apply for the Inspector/Risk Assessor certification in NJ.Current Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      Daytime Telephone Number  FORMTEXT      Alternate Telephone Number  FORMTEXT      E-mail Address  FORMTEXT      Permission for Release of Information I hereby give my permission to the Lead licensing office of the State of  FORMTEXT New York to release my information to the New Jersey Department of Health for purposes of obtaining a New Jersey Lead permit.SignatureDate  FORMTEXT      Section II - MUST BE COMPLETED BY out-of-state lead licensing agencyThe individual indicated above wishes to apply via reciprocity for New Jersey lead certification. Please provide the following information and return the completed form to the New Jersey Department of Health at the above address or fax number.Name and Address of Licensing Agency  FORMTEXT      Telephone Number  FORMTEXT      Fax Number  FORMTEXT      Applicant Licensing InformationDisciplineLicense NumberIssuance DateExpiration Date FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Does this individual have any pending /outstanding penalty actions against them?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, describe nature of pending/outstanding penalty actions:  FORMTEXT      Name of Licensing Representative (Print)TitleSignatureDate EHS-46 OCT 16 :E26Y|~  " $ & 0 2 4 \ z | ~ ༲whXhjt5CJOJQJUj5CJOJQJUmHj5CJOJQJU5CJOJQJj5CJOJQJU6CJOJQJ CJOJQJ CJOJQJ5;CJOJQJ 56CJ6>*@CJOJQJ6@CJOJQJ6CJOJQJ56CJOJQJ5;CJOJQJCJ5CJOJQJ" X:Y| <$  & F<$ h & F$ h$ & F$ h $ $$$$x$<<$ X:Y|~ & 0 4 | ' 6 7 f u v    ( B L P \ v   P j t x EF;<a    `|~ 4 | ' 0kh$?$$TH tF )h  $<$,$$TH t)+ $$$$TH)  & ' ( 6 7 8 f g u v w  졯쓯셯wtdj,5CJOJQJUCJjCJOJQJUjDCJOJQJUjCJOJQJUj\CJOJQJUjCJOJQJU6CJOJQJCJj5CJOJQJUmHj5CJOJQJU5CJOJQJ CJOJQJj5CJOJQJU''  ( P \ $<$+$$THP4 t)+($ hxH($ h8<     ( * > @ B L N \ ^ r t v    P R f h j t v յեՕՅuj5CJOJQJUjr5CJOJQJUj5CJOJQJUj5CJOJQJUj5CJOJQJUj5CJOJQJU5CJOJQJ CJOJQJj5CJOJQJUmHj5CJOJQJU.  P x hcZ$$$$A$$TH4 tF 8)v v $<$L$$TH4 t\8 H$)Z aa EF;<ablm  02FHJTVZ\rtyifCJj5CJOJQJUjV5CJOJQJU CJOJQJ5;CJOJQJj5CJOJQJUmHj5CJOJQJU5CJOJQJj5CJOJQJUCJOJQJmHjZCJOJQJUjCJOJQJU CJOJQJ5CJOJQJ(EF;ԐcZ$$,$$TH t)+ $$6$$TH4 t0)  $<$+$$TH04 t)+;<a0XZ\r|[6$$TH4 t0)   $6$$TH4 t0)`  $<$+$$TH4 t)+ an 0JTXZ\r.NPjtx 4>B\fj &046.0:6BV`bdr /  TNPRfhjtvxzκ㪚㪊zjj 5CJOJQJUj 5CJOJQJUj. 5CJOJQJUj5CJOJQJU5CJOJQJ;CJOJQJ5;CJOJQJ5;CJOJQJCJCJj5CJOJQJUmHj5CJOJQJUjB5CJOJQJU(.NPxD~$J$$TH t\h")Lp> ,$$TH t)+ $$ Bj 46:DD\$<$ (($$$$$J$$TH t\h")Lp>   024>@BDXZ\fhjľ̼̬̜|j 5CJOJQJUjh 5CJOJQJUj 5CJOJQJUj| 5CJOJQJUj 5CJOJQJU5CJOJQJj5CJOJQJUmHj5CJOJQJUj 5CJOJQJU*  "$&026.02&̵̼yiZS CJOJQJj5CJOJQJUmHj(5CJOJQJU5CJOJQJj5CJOJQJUjCJOJQJUj@CJOJQJUjCJOJQJU CJOJQJj 5CJOJQJU5CJOJQJj5CJOJQJUmHj5CJOJQJUjT 5CJOJQJU 6BV`bdr//J$$TH t\ #) N  f$)$$TH t)+ &4bd CJOJQJ CJOJQJ CJOJQJ6CJOJQJ(1h/ =!"#@$%tDText1tDText2tDText3tDeCheck1tDeCheck3tDeCheck2tDeCheck4tDText7tDText8vDText10tDText9tDText4tDText5tDText6DText12New YorkvDText11vDText13vDText14vDText15vDText16vDText17vDText18vDText19vDText24vDText25vDText26vDText27vDText28vDText29vDText30vDText31tDeCheck5tDeCheck6vDText320 [8@8 NormalCJ_HaJmH sH tH RR  Heading 1$<@&5CJ KH OJPJQJ\aJ TT  Heading 2$<@& 56CJOJPJQJ\]aJNN  Heading 3$<@&5CJOJPJQJ\aJBB  Heading 4$<@&5CJ\aJFF  Heading 5 <@&56CJ\]aJ@@  Heading 6 <@&5CJ\aJ22  Heading 7 <@&88  Heading 8 <@&6]F F  Heading 9 <@&CJOJPJQJaJ<A@< Default Paragraph Font,,Header  !JOJ Heading 1 Char5CJ KH OJPJQJ\aJ LOL Heading 2 Char 56CJOJPJQJ\]aJFO!F Heading 3 Char5CJOJPJQJ\aJ:O1: Heading 4 Char5CJ\aJ@OA@ Heading 5 Char56CJ\]aJ2OQ2 Heading 6 Char5\4Oa4 Heading 7 CharCJaJ:Oq: Heading 8 Char6CJ]aJ8O8 Heading 9 Char OJPJQJJ>J Title<@&a$5CJ KHOJPJQJ\aJ BOB Title Char5CJ KHOJPJQJ\aJ :J: Subtitle <@&a$ OJPJQJ>O> Subtitle CharCJOJPJQJaJ"W@" Strong5\2X@2 Emphasis56OJQJ],,  No SpacingaJ 88 List Paragraph ^m$"" Quote!60O!0 Quote Char 6CJaJ@@  Intense Quote #]^ 56aJ>OA> Intense Quote Char 56CJ:OQ: Subtle Emphasis 6B*phZZZBOaB Intense Emphasis56>*CJaJ<Oq< Subtle Reference >*CJaJ<O< Intense Reference 5>*CJ>O>  Book Title56CJOJPJQJaJ..  TOC Heading*@& $O$ burg13boldDD burg13bold1,dd[$\$ OJPJQJ.U@.  Hyperlink >*B*phFF  Normal (Web).dd[$\$ OJPJQJ, @,Footer / !1 D  &!|' ; a'7fv  &.:@KW]yO[da m s  " ( * 6 < > J P R ^ d g s y {  Z j v 1 FFFG$G$G$G$FFFFFFFF4FFFFFFFFFFFFFFFFG$G$F8@0(  B S  ?"Text1Text2Text3Check1Check3Check2Check4Text7Text8Text10Text9Text4Text5Text6Text12Text11Text13Text14Text15Text16Text17Text18Text19Text24Text25Text26Text27Text28Text29Text30Text31Check5Check6Text32(g/LzPb  + ? S h | [ w 2   !8w'A^et ) = Q e z  k 2 / 2  / 2 ewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhiteF\\dhss-ha-99\home\ewhite\FORMS\EHS- Lead Reciprocity Verification.dotewhite)\\dhss-ha-99\home\ewhite\FORMS\EHS-46.dotewhiteB\\dhss-ha-99\home\ewhite\FORMS\EHS-46 (with pending revisions).dotewhiteB\\dhss-ha-99\home\ewhite\FORMS\EHS-46 (with pending revisions).dotewhiteB\\dhss-ha-99\home\ewhite\FORMS\EHS-46 (with pending revisions).dot+LjfZujf|u1ԇ h`OJQJo( h`OJQJo( hhOJQJo(+LZu|u@p n n n 1 P@PP@P PP @PPPG:Ax Times New Roman5Symbol3& :Cx Arial7&@Calibri7@Cambria;Wingdings"hsJJ'J' x 5sٖ4$@20dI q?EHS-46 Request for Reciprocity, Verification of Lead Licensure Status with Another State Authorized by the US EPA to Administer a Lead ProgrameEHS-46, lead, reciprocity, licensure, verification, environmental, occupational, health, assessment, ewhiteewhiteOh+'0p0<L   , 8 DPX`hEHS-46 Request for Reciprocity, Verification of Lead Licensure Status with Another State Authorized by the US EPA to Administer a Lead ProgramHS-ewhiteRfEHS-46, lead, reciprocity, licensure, verification, environmental, occupational, health, assessment, t$EHS-46 (with pending revisions).dotewhite(4hiMicrosoft Word 8.0g@^в@ r(@-`P&@ r( ՜.+,D՜.+,| hp  [NJDOHRI 1 EHS-46 Request for Reciprocity, Verification of Lead Licensure Status with Another State Authorized by the US EPA to Administer a Lead Program Title 6> _PID_GUIDAN{9D6639BF-B967-4B20-BF40-74C3925DA28D}  !"$%&'()*,-./0123456789:<=>?@ABDEFGHIJMRoot Entry F]c]oP&иr(OData #1Table+WordDocument*DSummaryInformation(;DocumentSummaryInformation8CCompObjjObjectPoolиr(иr(  FMicrosoft Word Document MSWordDocWord.Document.89q