Notification of Deleading 2013 Jun 1713 05 02a Kevin C. Netto
413-203-3025 p.1
Department of Public Health& Department of Labor
Noumea rfON OF DELEADINC WORK
All sections of this form must be completed in order to comply with
the notification requirements of 3LG.L.C. 111§t97,
454 Cam 2200 and I05 CMR460.000.as most recently amended
Contractor performing project\IljjtN e lVC'lcIL, Licenses \yPte, Esp.Date S- -\3
Ua.l Paint lnspectoeNt LW eP Date of Inspection AL-tis #!\Ezp Date%L.i-\-%
ADDRESS OF PROJECT:
Street Address
Apt.Number
Lip
CSNCZACItt
edea■N`\it\Les\ aadre� e 5 \Ob
Property Ownm
fckphon Number y\ eS-12fic" , (link. ``o. 4C\)
!Minding Method:QWeVDry Scraping ❑Heat Cue
DDemoliloe ❑Caustics
QCavering 21Otbcr
If-Other selected.plutmexdain CebAe. \RSllaC-Hlt
Liquid Encapsulant
❑Replacement
Check one Th%elling is multi-family En Single-family) ✓ 1 Other 1
Start Date \n--d'l>1-
When will work be doe AM1t rML\
Completion Date \u-3,$-\-�
(Specify times on site) Weekends? No
Project Supervisor Name lip >_YSVt.1 Lkatsealitry.-\'4* Exp.Date C:\ "CS
Worker's Compensation Pnl icv Number `StocAQ1 ellby. TA Carrier fi+n�
In case of emergency'contact doY 1� U��E'� Tel.# 0y\3 '4S
(Contractor's Representative)
OFLFADIVC CONTRACTOR
The undersigned hereby states-under the pains and penalties of perjury,that bdshe Ins read and understood the Commonwealth of
Massachusetts Deleadine Refutations.454 CMR 22.00 and the Lead Poisoning Prevention and Control Rceublio as,105 CMR 460.800,and
that the information contained in this notification is true and correct to the best of bisater knowledge and belief.
Date \y-\1-_\� Signed
Company Name 3#i".A [l V tS494k )
Address v\t3' sCSO�D �C \sue .tt9 K C—Mast_
Tckpbone Number \3-rJa.1 jj at
0VEa2-i