185 Notification of Deleading Work 2013 Department of Public Health&Department of Labor
NOTIFICATION OF DELEAD1NG WORK
All sections of this form must be completed in order to comply with
the notification requirements of M.mgt C.111§197,amended
454 CMR 22.00 and 105 CMR 460.000,as
T AccuTech Insulation License ti DC00�Exp.Date 05102/2014
performing project —
Date of Inspection 0511612013
d Inspector Eileen
'S OF P OdF.0
185 North Main Street
ddress��
Insane
ry Owner Molly Feinstein
one Number (617)
Heat Gun
ling Mtthod:fl Wet/Dry Scraping Q Caustics
QDemolition 0 Other
QCoveriog
her"selected,ply explain
License# M33055
Exp.Date
Apt Numbers
Zip 01062 _
Address 80 Main Street, Northampton,MA
ck one: Dwelling is multi-family
971081204x' O1 15 -90 3
rtDate
ien will work be done: AM 8100 pM 5_00
oject Supervisor Name An1hOn IR Sr.
WC005-31-9996
orker's Compensation Policy Number
case emergency contact Jennifer Jennifer Keefe
:ontratorsRepresentative)
QLiquid Encapsulant
Replacement
0
�
I Other
Single-familYJ._. 1I�
C' 9I
Completion Date 07422/ 8
(Specify times on site) Weekends?WA
DS003366 Lip.Date 03/1912014
License#
Carrier CHART
413 583-5500
Tel.n_�
rcoNrRAC'L
fhe undersigned hereby states,under the pains and penalties aid the of Lead po,
that he/she has read and understood the Commonwealth of 0,and
Massachusetts Deleadivg Regulations,454 CMR 22.00,and tM1e Lead Poisoning Prevention and Control Regulaaovs,
that the information contained in this notification is true and correct to a best of his/. and belief.
Signed
Date June 19,2013
Company Name
AccuTech Insulation&Contracting,Inc.
Address 100 State Street,PO Box 376,Ludlow,MA 01056
Telephone Number (413)
OVER—*