46-48 Notification of Deleading Work 2007 r-----
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Department of Public Health&Department o
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed In order to c
the notification requirements of M.G.L.C.111§1
454 CMR 22.00 and 105 CMR 460.000,as most recently a
Contractor performing pryoject hdgsfeheontrack g Linea
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Lead Paint inspector `l'I� -D O �N11-> i Date of Inspection 4.1
ADDRESS OF PROJECT:
Street Address
U6,-14 X 4cto615f,
city -KtD1tf7QA11pfa/t-�.
Property Owner V 1Nlle Dt,VLI. Blip. Address M rs&7 Muhl t ✓^' 4M In ha
'II -58(� 55
c'0 0 101 q Exp.Date 10/14/00
to lob 'lemma-5)7 Eip.Date 111/0
Apt Number
Zip DI DGD
Telephone Number
Deleadlug Method:0 et/Dry Scraping
*mention
OCovering
s�o
If"Other"selected,please explain
❑Heat Gun
0 Caustics
0 Other
QLIquid Encapsuiant
Replacement
Cheek one: Dwelling is multi-family rti Single-family
V WAX
Start Date kIDU. 'LVI /UV I
Completion Date
Other I 1
Die, VI, .QDO1
When will work be done:/fA;M[pp_%/� p PM�/}(Specify times on site) Weekends? &JIA ^ p
Project Supervisor Name111W CA�-t-A Cl/ tK License* OO.. (, Rep.Date 10//I IDs
PIN Jo 33,) 797037 Carrier CI MUIlii1 1Cifixfp
Worker's Compensation Policy Number �r H� m p� (j n p
In We of emergency contact ■ka,i MciSPn Tel.4("70 ) Jlli J�tl)
(Contractor's Representative)
DELEADING CONTRACTOR
The undersigned hereby states,under the pains and penalties of perjurz that be he as read and understood the Commonwealth of
Massachusetts Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and
that the information contained in this notification Is true and correct to the best of his/her knowledge and belief.
Date I1 ! I Signed 1:1411/14111 NUV
v
Company Name b SI dit Co rarlog rvietsigic.
Address 55 4I& ny✓(e, 5pil i NA
Telephone Number I b- ( S I- 0 QC
OVER—)
Page 2 of 2
n accordance with Massachusetts General Laws C.111§197,454 CMR 22.00 and 105 CMR 460.M0,notice of the date and method(s)of
emoval or covering of paint,plaster or other accessible material containing dangerous levels of lead is to be provided and must be received
y the following agencies,at least (10)days prior to the beginning of deleading.
NOTIFICATIONS MAY BE FAXED.
Department of Labor,Lead Program,Division of Occupational Safety
399 Washington Street,5`s Floor,Boston,MA 02108 FAX:617-727-7568
Director,Childhood Lead Poisoning Prevention Program
Department of Public Health,Donovan Health Building.5 Randolph Street,Canton,MA 02021 FAX:781-774-6700
1. Occupants of dwelling unit
All other occupants of the residential premises,if any
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Place.,this notification must be made upon receipt of an
Boston,MA 02202 Order to Correct Violations or at least 30 days prior to
FAX(617)727-5128 initiating preventive deleading)
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
BE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORKFORCE DEVELOPMENT.
PROPERTY OWNER(If owner or unlicensed owners agent will be performing low-risk deleading work,complete the following): N In,
Property Owner Ageot(s)
Address
Telephone Number ( )-
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations,105
CMR 460.175,for owner/agent low-risk abatement and containment I further certify that I or my agent will be performing the following low-risk activities
(I have circled all that apply):
applying liquid encapsulant
capping baseboards removing doors,cabinet doors,shutters
applying rterior vinyl siding covering surfaces
I certify that all the mfonnnation contained in this notification is true and correct to best
the bbes off my knowledge belief.
ywledge and belie
Date I I I I '1 10 i Signed �Ir ' lG"fwveh n'-ocy wldt-
Revised 042007