4 Deleading Notification 2016 Department of Public Health- Childhood Lead Poisoning Prevention Program
Deleading Notification
se complete all sections of this form clearly.Incomplete or illegible forms will be returned.
I Paint Inspector Cr ) / cw dt
erty Owner Brost Pro he1.+1
erty Owner's Address /OJI .3-.1+
License# Inspection Date
Po.nj Trt'c Plw0-41 tic njf Zip Code /?t69
iorized person performing work: / /"`'' '( 4 t,)tiy
ress of authorized person /Yo 7 /VC;44 -('* W'^d'o-t Al E Zip Code 0 t z zo
phone Number(60.3) 4J rZ 7
Lic#/Auth.# /6(03-AL
ress where the work will be done:
ding Name(if any) Floor
et Address y ,j, y:// D--.Jr Apt No.
-pto.r..(i /NS Zip Code 0/ too The property is a multi-family ✓ single family.
_
tadina Method(s): .._ . .
ling paint intact t(high risk)
volition
tiling. . ...
nponent removal/replacement
ping
❑ Making paint intact(moderate
risk)
❑ Liquid encapsulant
❑ Covering
❑ Capping baseboards
/Applying vinyl siding on exterior
❑ Component removal(low risk
components)
❑ Other.
work will begin on2 /et//4 and will finish by 9 I L//4 The work will be done in the 0- am 4m or weekends.
:ase of Emergency Contact / "`s J tj e/IJ
'time Phone Y13- Zd/- ant
Evening Phone 9')-
roperty Owner must complete and sign the following information:
'that-only authorized persons who have complied with.the training requirements of the Massachusetts Lead Poisoning
tion and Control Regulations, 105 CMR 460.000,will conduct deleading work.I further certify that the authorized
s)will not exceed the scope of his/her authority and will be performing only those activities indicated above.All of the
rtion contained in this document is true and correct to the beestt of my knowledge and belief.
to kr, Z.0/8 Signed te�eame, .�f°"-.
�e following people/agencies must be notified ten days before beginning work: *
cupants of the dwelling unit
1 other occupants of the residential premises,if any work will be done in the common areas
Fax(781)774-6700
dldhood Lead Poisoning Prevention Program,DPH
WRHO
Randolph Street,Canton,MA 02021
:bestos and Lead Program,DLS
Stanford St, 1 Floor,Boston,MA 02114 Fax(617) 626-6965
,cal Board of Health/Code Enforcement Agency
's If the hbme is on the Slat e Register of Historic Places,call the MA Historical Commission at(617)727-8470.