108 Deleading Notification 2001 fi El
Department of Public Health/Department Of Labor It Industries I
rNMt II „
NOTIFICATION OF DELEADING WORK FIL NUMBER
J
a ' 2 LWI I u
All sections of this form last be completed in order to comply with NO'- AMPTON COARD
the notification requirements of M.G.L.C. 111 § 197, OF HEALTH
454 CPR 22.00 and 105 CMR 460.000 as most recently amended
Contractor performing project' Q9 e_Ntt\t License /iC y �°°
Exp. Date -3Q{a
Lead Paint Inspector §Ck V&
eCt-c
\--texe.. License e Iva,-)ay
PROPERTY (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner
Agent(s)
Address
Telephone Numbe
I certify that 1 have complied with the training requ)rencnts of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 CPR 460.175, for owner/agent low-risk abatement and
containment. I further certify that I my agent will be performing the •-following low-risk activities (1
have circled all that apply):
applying liquid encapsulant capping baseboards removing ng tlonrs, 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: Signed:
ADDRESS OF PROJECT'
Street Address \b'6 ti '1,q\ Apt. Number Ne3-\-.. N
city NoAt.trvs\Act. Zip O\Obn
PropsrtyOwner 'Sn et\ Address
No2oti ��c� .N.T4A oNo C3Q)
Telephone Number%S_S
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
C Covering Other
If "Other" selected, please explain
Liquid Encapsulant
Replacement
:heck one:
dwelling is multi-family `7 single-family,
other
Page 2 of 2
Start Date -1- c7Z -�\
Completion date 1 -a.°J-0\
When will work be done: amltt30 pmyyt(Specify times on site) Weekends? 710
Project Supervisor Name\CL•FY\c\ ` _1\40-\\C-, License#..\'Se.5 Exp. Date'\- mod.
Workman's Compensation Policy Number`''<\ 'C Tibe9&C \S Carrier%.S\E\t\j
In Case of Emergency Contact: (Contractor's Representative)
In accordance with Massachusetts General taws C. 111 5197, 454 CM 22.00 and 105 OW 460.000, notice of the
date and method(s) of removal or covering of paint, plaster or other accessible materials containing
dangerous levels of lead is to be provided aM east be received by the following persons, at least L
business days prior to the begiming of deltading. NOTIFICATIONS MAY BE FAXED.
1. Department of Labor 8 Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Ram 1106, Boston, MA 02202 FAX: (617)727.7568
2. Director, Childhood Lead Poisoning Prevention Program a'7511-%`1.
Department of Public Health, 305 South Street, Jamiu Plain, MA 02130 FAY: (617) 983-6931-
(617) 522-8735
3. Occupants of dwelling unit
4. All other occupants of the residential premises, if any
5. Local Board of Health/Cede Enforcement Agency
6. Massachusetts Historical Coenission (if premises are fisted an the State Register of Historic
220 Morrissey Blvd. Places, this notification asst be made upon receipt of an
Boston, MA 02202 Order To Correct Violation or at least 30 days prior to
FAX: (617)727-5128 Initiating preventive deteading)
DELBADING CONTRACTOR:
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 MR 22.00, antI,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.
/
Signed !/"Cut, < ol-L)
Date -1 -\C ---C \ J n
Company Name: ` `�V\\\ l t•.RC\
Address:
Telephone Number: \-)- 12O%."}-3\\oFj
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL HE RETURNED HY D.L.I.