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421 Deleading Notification 2004 Ell !Opel PPIA mIVVL/VVJ a n,,pa tment at Public Health/Department of Labor&WoddcraDevebpmeat NOTIFICATION OF DELEADING WORK All stations antis form mmt be completed I.marts comply with the noafealioa requiremeats of M.GY C.1l1 097, 454 CMR 22)10.ad 105 CAM 460.900,as most recently amended tractor performing project Abide,Inc. (F.Ti1lij se DC001619E/ 8/30/05 d Paint Inspector Date of Inspection MESS OF PRWECL VA MC et Address_l �1 NOC�'Vh MQ;^ Sine+. warn- 11 B B, 4$A, 1% ) 19A, *prN.mw 21/4) 2) S) 22 ) 233 Levels ) M A rip Olo : arty Owner V A M L bkensl_ESp.Date phane Number 4 )I— S8-2 — '309 `I adeg Ofatbsd: alDry gmap® Heat Gen DemaDtsa Camtir Coverlet railir0 theft selected,please explain Pre-CAkan.ry..5 Cn MC aJrI CPSS 7dguM Facapsahat Repleeemnt atone: Dwelling is multi-Smiled Si gbsmiily Other 17-( freA;Le 1%c:I lied 4n veicrani) Date 1/3105 Completion Date ) '31 /05 a will work be dose AM7:00pM 5:080 • ,data m site) Weekeadd no atsopervlmrName Jerry Gray Unmet DS00377Q Sjg105 &es Compensation Polley Number ANC7013278012003000 Cosier ATM e of emergency rkwct Frank Tilli, Abide, Ingtd.p 4 13 525-0644 radar's Repnm.sadve) ;Warn .dersigned hereby states,under We pain and penalties of perjury,that befsN In read ma ndemtood Ike Cwmenwealth of wheels Weeding Rego6does,454 CMR 22.00,*ad the bead Poisoning Pnveathe ad Cannel Reaalalioas.116 CMR 4604N,and he information matrind Ism this sedgcation Is ha.and cornet N the bleat of banter knowledge sad belief 12/22.by s ignd/red" (A4A . yNwe Abide, Inc. 1 Frank Tilli, Abide, Inc. P.O. Box 886 (483 Shaker Rd. ) , East Longmeadow, MA 01028 tone Nmber (4j 3) 525-0644 OVER-* 004 WED 15:55 FAA )5010 Page 2 of 2 ,Fan cardana with MaruAoens General Lm C.111§197,454 ChM 220a and 105 CAM 46&010,them&the dataud method()of oval or covering of ptie4 potter tattleratussibk materials eataking dagerom knit*find is to be pnvidW ad most be neared be following agencies,at lead 121(1g)dap prior soda beginningofdekadiag. TIFICATIONS MAY BE FAXED. Department of Labor and Workfare Development,Division of Oct anginal Safety 399 Warbiaglen Strut,Sa Floor,Bonten MA 0210$ FAX(617)727-7565 Director.Childhood lad Pokoviag Prevatia Program < 3 Department of Public Realmh,56 Roland Street,Salk 1N,Boston,MA 1212t FAX*YfiM69436-. —rte--j79-67th Occnpats of dwell*unit All other occupants of the rddatint premises,if any Load Board offload/Cade Eofanentma Agency f Leet15�AJoc1)n np\cr ) FAQ 041 i sfl-1221 Massachamtts IfittarkalCoanzaissioa 220 Morrissey DM. Boston,MA 02202 FAX(617)727-5128 (If premises are listed a the State Register of!Stork rhea.106 notification is be aide oath receipt ofa Order to Correct Violations or at least Meth prier to iagladag preventive dakadiep IIFICATIONS SHALL BE COMPLETED IN11BJR ENTIRETY,DATED M DSIGNE -INCOMPLETE NOTDICAT10N4 WILL NOT AO(TPn»AND WILL BE B61DRNED BY Tia DEPARTMENT OF LABOR WORKFOR EDEVELOP ME0T. )PER'IY OWNER(If owner orunlicensed owner agd will be pateisg lowish ddadbgnods oomp1da the folloab$): peaty Owner Agate) Jo Densmore — Abide. Inc. Irges P.O. Box 886 (483 Shaker Rd. ) , E.Longmeadow, MA 01028 "loss Number (413). 525-0644 tifythat I hove mnplied with detrainingn4oirmats of the CommooweaBh ofMemdns tts Lind Poisoning Amelia,sod Cad RegvWkas,105 8460.175,forowsonkgmt kw.ridabg®mtid aobkmmt I farther tatif'that I array agent wig be perfuming the following loot-risk activities we circled all that applyk •pplylsg liquid enapaknt appiag Mmboardr removing doors,abut door,Suntan applying exterior vinyl aiding covering surfaces rtify that all the information contained is this noggction is tram ad mreclm the ben of my knowledge and belief Signed JO Densmore - Abide, Inc. Authorization § 04488-AL 4 WEN 1J:04 ran a b i d e Abide, Inc., Environmental Contracting LEAD NOTIFICATION FAX COVER SHEET ; DATE: c2122-joy ATTENTION: FAX#: I `'irector,CLPPP(Boston) 781-7746700 [t/ J ireetor,LEAD PROGRAM(Boston) - 617-727-7568 t4 Town/Cityof (a mAAkrvon - "VI-587- 12-z( (Ladd Beard of nnath) [ I Massachusetts Historical Commission 617-727-5128 FROM: FRANK TILLI/ABIDE,INC. REGARDING: (✓] PROJECT NOTIFICATION [ ] REVISED NOTIFICATION [ 1 OTHER NUMBER OF PAGES (including this one): -% COMMENTS: If you experience problems in receiving this transmission,please.cal:413-525.0644. CONFIDFNIwuTY NOTICE The dmammm ccm parrying Mu t dcaopy transmission may emem eaofdmfiil and pivifeaed . .. . afmmetioe from A6id41s This'damages is icede4 Redwine oflhead&eMN individual cc eatity. If you re not Ste;iiamded recipient,beware that any diecISvyymy(ISIS c. . as Of themaat ofditbammldaaw goithited.nymbeve,cdvedWu m me ari Rem, plmc^mtl m by pbee(9t1525O644)immediately. Thank you P.O.Bar 886 East Longmeadow,MA 01028 Phone 413-525-0644 • Fax 413-525-0678 • www.abideinc.com stendaN TERMS AND COMMONS Why peymem for aver upon presentation of brvgce. Modem unpaid after 30 DAYS ara past due and subject to CHARGE computed eta monthly rate of 1 1/2%(ANNUAL PERCENTAGE RATE OF 1S%)c the maximum percentage allowed by the mw. talent Is - tor Iv*and collegial costs I necessary to celled past due amounts. a Department of Public Realtb/Department of Labor&Workforce Development NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of M.G.L.C.111§197, 454 CMR 22.00 and 105 CMR 460.000,as most recently amended SEP 16 20e4 ' N' ' �IAMPTON BOARD OF HEALTH forming project VA I".e(1(at Cosier License Of Exp.Date Lector /(-T, Date of Inspection License# Esp.Date PROJECT: yak NortA iTin 5Y-. ROOM-Apk Number Put OBitk ,4 i I$ 1 n Zip f�l tOZ,� 3 . V� er 1f'f III I I l -en-mr Address LW (Vat If IQln St) Lei. 1 f t0.. GIQ53 mbertn -5R4-4o4n hod: 1'iL`a'/s Scrapiu� Heat Gun Demolition Caustics Covering Other cled,please explain Liquid Eocapsulaut Replacement Dwelling is multi-family Single-family Other'HOT t 1-71L IRCJ( L1Cf,19 • Completion Dat irk be done: AM 730 Ply[fD0 (Specify times au site) Weekends? 0✓1/11117 +drn t1 rvisor Name 16.1ACi, LacnM\4,3 0 , License#D.S Ery.Da Carrier impensation Policy Number tergency contact 's Representative)?)gk2G Sahli Ai vs.# (4/3. ) co-UO1O e%r-uCsC2 . 4/3 x-3035 G CONTRACTOR sued hereby states,under the pains and penalties of perjury,that he/she has read and understood the Commonwealth of tts Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and srmation contained In this notification B true and correct to the best of his/her knowledge and belief. Signed lame fy A Li4 M edi(ol Centre, t/11 pall whim st. Number �$t� —1/0Y0 OVER-a Paget of 2 ith Massachusetts General Laws C.111§197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and method(s)of ring of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received ;agencies,at least TEN(10)days prior to the beginning of deleading. ONS MAY BE FAXED. tmeat of Labor and Workforce Development,Division of Occupational Safety sshiegtoo Street,Spa Floor,Boston,MA 02108 or,Childhood Lead Poisoning Prevention Program tment of Public Health,56 Roland Street,Suite 100,Boston,MA 02129 FAX(617)2848436 mots of dwelling unit her occupants of the residential premises,if any Board of Health/Code Enforcement Agency achusetts Historical Commission forrissey Blvd. in,MA 02202 (617)727-5128 (if premises are listed on the State Register of Historic Places,this notification must be made upon receipt of an Order to Correct Violations or at least 30 days prior to Initiating preventive deleading) DNS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT '.D AND WILL BE RETURNED BY THE DEPARTMENT OF LABOR&WORI FORCE DEVELOPMENT. • )WNER(If owner or unlicensed owner's agent will be performing low-risk deleading wod:,complete the following): aer Agent(s) umber_( )- have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention and Control Regulations,105 y for ownedageot low-risk abatement and containment. I further certify that I or my agent will be performing the following low-risk activities I all that apply): lying liquid encapsulant lying exterior vinyl siding all the information contained in this notification is true 4 correct to tb best.. my knowlc a and belief. f • a La y1! capping baseboards covering surfaces removing doors,cabinet doors,shutters Signed lilt :t atc arming � cttprojje( . octor�y --Date of Inspection PROJECT: Department of Public Health/Department of Labor&Workforce Development NOTIFICATION OF DEI LADING WORK All sections of this form most be completed in order to comply with the notification requirements of M.G.L.C.111 0.97, 454 CMR 22.00 and 105 CMR 460.000,as most recently amended nber hod: I .• 11 ,l• Demolitio Covering ctd,please explain Dwelling is multi-family Ileat Gun Caustics Other f^: Exp.Date Licensed Exp.Date SEP 16 2?' J 1AMPTON BOARD OF HEALTH eCell P a.31131 1 . 11, �tph Number Df fti zip liquid Encapsulant Replacement Single-family Otbcr ��l L121b3f/S4V Completion Date srt be done: AM Z0irPM/„ , (Specify times on site) Weekends? — --I �.� nil" license q Exp.Date rviror Name Carrier ,mpeanatiou Policy Number Q 4� Tel.d_( t113 ) S i 413 5-4-3635- sergency conta 's Representative) SC?}nIMI y3 C CONTRACTOR igned hereby states,under the pales and penalties of perjury,that he/she has read and understood the Commonwealth of :tts Deleadiog Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 CMR 460.000,and ormation contained in this notification is true and correct to the bat of his/her knowledge and belief. pled OVER-' Page2of 2 with Massachusetts General Laws C.Ill§197,454 CMR 22.00 and 105 CMR 460.000,notice of the date and method(s)of eriug of paint,plaster or other accessible materials containing dangerous levels of lead is to be provided and must be received g agencies,at least nn(10)days prior to the beginning of deleading. IONS MAY BE FAXED. rtmeut of Labor and Workforce Development,Division of Occupational 17S 727-7568 7568 Washington Street,5n Floor,Boston,MA 02108 :tor,Childhood Lead Poisoning Prevention Program n,MA 02129 FAX(6171284-8436,rtment of Public Health,56 Roland Street,Suite 100,Boston, ,pants of dwelling unit ■her occupants of the residential premises,If any „Board of Health/Code Enforcement Agency sachusetts Historical Commission Morrissey Blvd. ton,MA 02202 ((611)727-5128 (if premises are listed on the State Register of Historic Places,this notification must be made upon receipt of an Order to Correct Violations or at least 30 days prior to Initiating preventive deleading) IONS SHALL BE COMPLETED IN THEIR ENTIRETY,DATED AND SIGNED-INCOMPLETE NOTIFICATIONS WILL NOT ED AND WILL BERECURNED BY THE DEPARTMENT OF LABOR it WORKFORCE-DEVELOPMENT.- OWNER(If owner or unlicensed owners agent will l be performing low-risk deleading work,complete the following): veer Agent(s) Numbed )- I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Preventio and ndw�lol Regulations,s,e105 75,for owner/agent low-risk abatement and containment I further certify that I or my agent will be performing g ed all that apply): .. baseboards removing dean,cabinet doors,shutters plying liquid eucapsWaot ca PPI°g 'plying exterior vinyl siding covering surfaces a all the information contained in this notification is tree coned t • to t m oe wledge to thed belief /5/011 Signed in ^4 �� '