108 Deleading Notification 2004 •
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M1
Net
Department of Public Health/Department Of Labor 8 Industries
NOTIFICATION OF DELEADING WORK FILE NUMBER
All sections of this form must be completed in order to comply with
the notification requirements of M.G.L.C. 111 4 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
Contractor performing project
VV-ke,NP� License 1'UCU143Exp. Date`U-d
Lead Paint Inspector 1 •\PV\ c *st \\,cav■ License # '- `:\
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-__,
rook deleading work, (
complete the following ): __
po6 2004
Telephone Number
vuEJOH ,
gMpTCy ZOAt
t 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. 1 further certify that 1 or my agent witl be performing the r-following Low-risk activities (t
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this notification is true and correct to the best of my
knowledge and belief.
Date:
Property Owner Agent(s)
Address
ADDRESS OF PROJECT:
Street Address
Signed:
City V J,---- --ort \V cl
Apt. Number 12-""
Zip 4:-:.\ vL ‘
"`CCU �-F�\
PropertyOwner �[>\\ c+ Address
Telephone Number 1-\\ D-rJ .- IF"..
Deleading Method: Wet/Dry Scraping Heat Gun
Deno ationJ Caustics
Covering Other
we.ia. 'wC- 1ina
Liquid_Encapsulant
( Replacement/
If "Other" selected, please explain
Check one: dwelling is multi-family V single-family
other
Page 2 of 2
Start Date r>- ?_?\ Completion date C\
When will work be done, aml_,?Cl• ye 6C(Specify times on site) Weekends? 'l0
Project Supervisor Name \'&V\1C.-Ni'ZK'. License/“ \VSO Exp. Date\.0-a.\- _E-.)
Workman's Compensation Policy\Number\S)C.�C7 1 :V4,5-1-tts Carrier <.,
In Case of Emergency Contact: ln4\Nta ll 1• P�Ti ■ (Contractor's Representative)
In accordance with Massachusetts General Lae C. 111 4197, 454 Oe 22.00 and 105 aM 460.000. notice of the
date sad methods) of removal or covering of Pint, plaster or other accessible materials containing
dangerous levels of lead is to be provided and wet be received by the following persons, at least ton
business days prior to the beginning of deleading. NOTIFICATIONS NAY BE FAZED.
1. Department of Labor & Industries, Division of Asbestos and Lad Enforcement
100 Cambridge Street, Rea 1106, Batt, RA 02202 FAIL: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program et-
Depertant f Public Health, 305 South Street, Janice Plain, NA 02130 FAR• 1617
3. occupants of dwelling snit C(617) 522-8735
4. All other occupants of the residential premises, if any
S. Local Board of Ralth/Code Enforcement agency
6. Nasachusetts Historical Ceeeissit (if praises are listed on the State Resister of Vittorio
220 Morrissey Blvd. Place, this notification an be made upon receipt of an
Boston, HA 02202 Order To Correct Violations or at last 30 days prior to
FAX: (617)727-5128 initiating preventive Stadia)
C0R91LCl'OH
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
regulations, 454 OCR 22.00, ant'Lead Poisoning Prevention and Control
Regulations, 105 CMR 460.000, and that the information contained in this
notification is true and correct to the hest of his/her knowledge and belief. ,
Signed n,2/, =
/
Date $-11 -e`\
Company Name: \\ VAC,, �.. lt‘t\f-l'\
Address, c`
• --% `mot
Telephone Number:
NOTIFICATIONS EHALT. BE COI@LETED IN THEIR ENTIRETY, DATED AND swam-
INCOMPLETE NOTIFICATIONS SILL NOT BE ACCEPTED AND NILL RE RETURNED ST D.L.I.