230 Deleading Notification 2011 Department of Public Health- Childhood Lead Poisoning Prevention Program
Deleading Notification
m 1 e t e all sections of this form clearly.Incomplete or illegible forms will be returned.
p
License i/31
it In s p ector 5y/ l f4iLkn
Owner 'J,C��,[,'p�`,✓�.�
Owner's Address n)r1 o ' •
;d person performing work
tf authorized�p�erson®/0 �
. £1 X Li L3[
e Number 9) 33
where the work will be done:
Name(if any) a. 3,1 tvc'rlex FlApoor oor //
dress t. •!- - -
The property is a./rrulti-family single family.
4-
Inspection Date e)6,/.i//1
Zip Code /o(nd AA •
Lic#/Atith.# /ag9? —1Y•'�
Zip Code_6/(a
.k. s /fl-S.
Zip Code
1g Method(s):
paint intact (high risk)
on
lent removal/replacement
la Making paint intact(moderate
risk)
❑ Liquid encapsulant
overing
rt-apping baseboards
plying vinyl siding on exterior
cr-COmponent removal(low risk
components)
❑ Other:
-k will begin wry, t`
and will finish b %3P it The work will be done in the 4 Goth
of Emergent Contact
e Phone e 7
Evening Phone S (??;-
weekends.
rty Owner must complete and sign the following information:
t only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
and Control Regulations, 105 CMR 460.000,will conduct deleading work. I further certify that the authorized
ill not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
contained in this document is true and correct to the best of my knee d belief.
Da,a9 lI Signe
(lowing people/agencies must be notified ten days before beginning work:
ants of the dwelling unit
ter occupants of the residential premises,if any work will be done in the common areas
food Lead Poisoning Prevention Program, DPH
Fax (781) 774-6700
HO
.dolph Street, Canton, MA 02021
tos and Lead Program, DLS
niford St, 1°Floor, Boston, MA 02114
Board of Health/Code Enforcement Agency
If the home is en the State Register of Historic Places,call the MA Historical Commission at(617)727-8470.
Fax(617) 626-6965