108 Notification of Deleading 2000 Department of Public Health/Department Of Labor 6 Industries
NOTIFICATION OF DELEADING WORK FILE NUMBER
ALL sections of this fore oust be completed in order to comply with
the notification requirements of M.O.L.C. 111 § 197,
454 CPR 22.00 and 105 DN 460.000 as most recently amended
.rector performing project +v\c\ta .1" ,. License #C7. -\ ExP•
l Paint Inspector P\'C\C'P C scst*e\e.. License
Date
. R (If owner or unlicensed owner's agent will be performing low-
t deleading work,
aplete the following ) :
party Owner Agent(s)
Tess
aphone Number
rtify that I have complied with the training requirements of th�mmonwealth fiMassachusetts aLLeead
oning Prevention and Control Regulations, 105 04R 460.175,
aliment. I further certify that I or wry agent will be performing the +-following Low-risk activities (I
circled all that apply):
ying liquid a capsulant capping baseboards reeving doors, cabinet doors, shutters
yang exterior vinyl siding covering surfaces
rtify that all the information contained in this notification is trot and correct to the best of my
Ledge and belief.
.e: Signed:
IRESS OF PROJECT:
:eet Address \G'\ CL) e\
:y 1 YCSZO�clR
Apt. Number k '`\\
(� ° Address tom. \ \\ \ a
apertyOwtter �1 \� 1\'f'�a�
Lephone Number
Leading Method: Wet//�D�rtiySScraping
COgeri
l' g c
"Other" selected, please explain
Heat Gun
Caustics
Other
Liquid Encapsulant
Replacement
eck one: dwelling is multi-family \i" single-family
other
F
I
I
V
a t
Page 2 of 2
Start Date \O --�ill-1�O Completion date \SI. -15--).
When will work be done: am],_°_i) peaIg/Specify times on site) Weekends? \\c
Project Supervisor Name 7)-tm4ycz ..Ne'c\t-- License `\ tq3 Exp. Date
Workman's Compensation Policy Number`NM_\-t %Y52,dC\R Carrier 2 ynC S--.
In Case of Emergency Contact: ' � .NE\i�. (Contractor's Representative)
"NMI,-ca-1- \`aF.
In accordance with Massachusetts General Less C. 111 5197, 454 CMR 22.00 and 105 Opt 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 and at be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS NAY BE FATED.
1. Department of Labor 6 Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Rope 1106, Boston, lU 02202 FAX: (617)727-7568
2. Director, Childhood Led Poisoning Prevention Program 3E%`\-tab
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617)983-6931
(617) 522-8735
3. Occupants of dwelling nit
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Cosission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification ut be made upon receipt of an
Boston, NA 02202 Order To Correct Violations or at least 30 days prior to
FAX: (617)727-5128 initiating preventive deleding)
DHLNADING 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 CMR 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.
Date �Y:C,C� Signed (' ) /-M77?-72)
Company Name: �P v�cSL.-A\4P \ L
Address: 'yamJ. AV�AAC1.z��,��k_£^ vAA � )R1�. GV0'�1
Telephone Number: 'A\:'l-`J� i 5\\0F^.
NOTIFICATIONS SHALL ES COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED ST D.L.I.