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a <br />February 17, 2016 <br />Based upon the review of your license application, the Indiana Lead and Healthy Homes Program has determined that you have fulfilled the <br />requirements of 410 IAC 32 and are eligible for licensing in the following lead -based discipline: Lead Risk Assessor <br />Enclosed is your Lead Risk Assessor license card. This card must be available for review at all times while you are implementing a lead - <br />based project. <br />This license may be revoked, pursuant to 410 IAC 32-2-81 if you: <br />(1) Vioiate any requirements of these rules (410 IAC 32). or any other federal, state, or local regulation pertaining to lead -based paint <br />activities. <br />(2) Falsify information on your application for licensing. <br />(3) Fail to meet any qualifications specified in 410 IAC 32. <br />(4) Conduct a lead -based paint project, or related lead -based activity, in a manner that is hazardous to the public health. <br />Your license is valid effective 03/29/2010, and will expire on 0312912019, as indicated on your card. We suggest that you attend the <br />required training and submit an application for license renewal early to insure your license does not lapse. In order to avoid re -taking the <br />initial training course, you must attend a refresher in the discipline yd'u are seeking a license within three (3) years from the date of issuance <br />of your last training course certificate. <br />Indiana State Department of Health <br />Jason 1,. G a'nser <br />Lead Risk Assessor Lidense I ND000502 <br />Effective: 03/29/20110 Expiration: 03/29/2019 <br />Birth Date: 01/10/1974 Gender: M <br />Height -00 Eye Color: BLU <br />Weight: 200 Hair Color:` BRO <br />Indiana State Department of Health <br />Q' 100 N. Senate Avenue, N855, <br />N <br />Indianapolis, Indiana 46204 <br />h <br />Lead Risk Assessor <br />Certificate NpMber Expiration Date <br />IND000502 0312912019 <br />,Jason A. Ganser <br />Jerome M. Adams, MD, MPH <br />State Health Commissioner <br />Indiana State I Department of Health <br />STAVE FORM 49122 �9- <br />