421 BLDG 11 Notification of Deleading Work 2005'2005 15:22 FAA 41JUO4J10
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Department of Public Health/Department of Labor&Workforce Development
NOTIFICATION OF DELEADING WORK
All sections of this form muse be completed in order to comply with
the notification requirements of MO.L C.1114197,
454 CMR 22.00 and 105 CMR 460.000,as most recently amended
rector perfecming prof f i/f 1 License$i Exp.Oak
Paint Inspector Date of Inspection Licenm# Pap Dee
CRESS OF PROJECT;
et Addrtaa IPA (\LORI. If ` t
IPPASI
eery OOacr VfT, Merl i/r l Crtirrer
Phone Numbs 1413-54-G -tiesuO
acing Method; 8Drye
Deana Hon
Covering
Muir"selected,please manna
Apt Needier 11A(7yl
zip OID
Addsea SQwte
Heat(run
Caustics
Other.
Liquid Enapsulmnt
Replacement
ck one Dwelling is multi family Single-family
*Date ID114'6S
in will work be dense: AAMM,y.3y IPM.q o (Specify tires on site) w�
[en Supra isor Name /)III!7 a aCCM6e.- Licaroe% .rEal.Date,CiTr IP
TOb;rn '
:km's Compensation PdiVengt
contact
of emergency ntact kiE
amactor's RepresentalYe)
.,EADING CONTRACTOR
Carrier
TcL0OM ) 4-69-4a40
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undersigned hereby Mat.ands the pains and pmaltia of perjury,that helshe ha read and understood the Commonwealth of
inchoate.Deleading Reguistes,454 CMR 22.00,and the Lead Poisoning Prevention and Control RegulathmeN 105 CMR 460,000,and
the iofornacon contained in this notification is true and cornet to the best of his/her knowledge and belief.
npany Nana
Den
Signed
ephme Number
OVER-b
OCT - 5 “
2005 15:22 ran asaooto.o
•
Page of 2
tecordanm with Massachusetts Cutc+al I.a..a C 111 9197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and.MOd(s)of
chat or mscrup of paint,platter or other acrostbl<mahriala containing darmgreua leads of lead is to 0e provided
amt must be received
the Miming agencies,at least TEN(10)days plot torte beginning of dde.ding.
)TIFICATTONS MAY EE FAXED.
Department of Labor.Lead Program.Division of Occupational Safety
399 Washington Street,5n Floors Boston,MA 02108 FAX'617-7247563
Director,Childhood Land Poisoning Prevention Protease
Department of Public Reath,Donovan Health Building,5 Randolph Street Canton.MA 02021 FAX:781479-6700
Occupants of dwelling unit
All other occupants of the residential ermine,if any
Lord Rated of Hellt/Codc Enforcement Agency
Massachusetts Historical Commission
220 Mcmbwv Blvd.
Boston,MA 02202
FAX(617)727-5128
Of premises are listed on the State Register of Historic
Place,this notification most be made upon receipt of an
Order le Correct Violsdo s or at least 30 days prior to
initiating preventive ddtedung)
OTDICATIONS SHALL DE COMPLETED IN'THEM ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT
iE ACCEPTED AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORRF'ORCE DEVELOPMENT-
ROPERTY OWNER(If owner oc unlicensed owners agent will h performing yew-ritic dduAog work,complete the following)'.
h'oherry Owner Agents)
Telephone Number_( )-
certify That I l avecom$id with the Mining tequicemem of the Commonwealth of Massachusetts Load Paismuog Prevention and Central Regulations. 105
:MR 460.173 for owr 1agent low.riskabatement end containment Ilather terrify tell or my agent will be performing Pc following bwriskactivitiel
1 have elected all that apply)'i
applying liquid enelundent capping baaeho.Ns
appyhst exterior vinyl siding covering surfaces ad
I certify that dirks information contained in tug notification is true cannel to the bbetst of mE knowledge/d belief
Dare O :7 Sipid�Wm'c+ C (ll%,l(14'
removing dnen,abbe[door,ahathrs
08104
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teans Administratioir_
is transmission is intended only for the use of the person as office to whom it is addressed and may contain information that is
vileged,confidential,orprotected by law.
I others are hereby notified that receipt of this message does not waive any applicable privilege or exemption from disclosure and
rt any dissemination,distribution,or copying of this communication is prohibited.
as document may contain information canted under the Privacy A .SUSC 552(4eandlor the
e in Heath Insurance
uran with those Portability aand
ions.
xohcans inf Act(PL s 04-191)
person and
and its sensitive various
an mast et atedah0or . If this correspondence contains healthcare .
formats it isb ing irovidedtl and aftp and tit treatednfromtgty.
Potmation.it is befog provided to you after appropriate r�horizationfaam the patient asunder circumstances that do not requite
dent amhoriation. You,the recipient,are obligated to maintain it in a safe,sere and confidential mamas. Redisclosure without
Iditionalpatient consent or as permitted by law is prohibited. Unauthorized redisct:num or estop notify tdatalih
ibjeoa you to application of appropriate sanction If you have Teceived dais cotnspaodence
rawdiately at the telephone
camber shown below awl destroy any copies you have made. Thank you- Revised 8JIA3
A
VILA FAX TRANSMITTAL
VA MEDICAL CENTER(Northampton)
DEPARTMENT OF VETERANS AFFAIRS
421 N. Main Street
CONFIDENTIAL Leeds,MA 01053-97M CONFIDENTIAL
To o men
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SIGN MOW AND FAX BACRTO ACKNOWLEDGE RECEIPT OF ATTACHED.THANKS'
ACKNOWLEDGEMENT OF RECEIPT:
SIGNATURE
DATE