108 APT#D2 Notification of Deleading 1999 Department of Public Health/Department Of Labor 8 Industries
NOTIFICATION OF DELEADING WORE FILE NUMBER
Alt sections of this forum wet be completed in order to comply with
the notification requirements of M.G.L.C. 111 1 197,
454 DIR 22.00 and 105 CNR 460.000 as most recently emended
\� 5, � OC\Vq�
Contractor performing project \\t 'v\)VC T-) License I Exp. DateVaa%-'
Lead Paint Inspector Pct -.e C`�'ttcNs\flx License t Mala1/4k
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ): ,j 1 pp
Property Owner Agent(s)
Address h;(11/ 9 9 IOnn
Telephone Number _ _�
...?TO\COMO OF HEALTH!.
I certify that I have coaplted with the training requirements of the Commonwealth of Massachusetts t e�'�-�•
Poisoning Prevention and Control Regulations, 105 MR 460.175, for owner/agent Low-risk abatement and
containment. I further certify that I or ay agent will be performing the t-following low-risk activities (I
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: - Signed:
ADDRESS OF PROJECT: p C � q�
Street Address \C C \ CSC% Apt. Number \.J-a
City I YO -SVOh
PropertyOwner
eo\
Telephone Number "\3 -t64Qa- aa•`yJa,
Zip C:lNt\Ot"Th
Address a3 \`p ��
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
( Covering.) Other
Noce`\t..,CnP.
Liquid Encapsulant
Replacement
If "Other" selected, please explain
Check one: dwelling is multi-family N/ single-family
other
Page 2 of 2
Start Date \\- .7S-C\- \S Completion date \\--056-v-RQ
When will work be done: am i j p�nl4.43(1(Specify times on site) Weekends? X\G
Project Supervisor Name\GZ2'1\h 1 e4T(I: Licenser.2\Ac42\ Exp. Date\- -t.)G
Workman's Compensation Policy Number \\ A.:CSVi5ec3\q Carrier
In Case of Emergency Contact: S ' tj7 h\. cp
In accordance with Massachusetts General Laws C. 111 §197, 454 CMR 22.00 and 105 OM 460.000, notice of the
date and method(s) of removal or covering of paint, plaster or other accessible materials containing
dangeras levels of lead is to be provided and must be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS MAY BE FAXED.
(Contractor's Representative)
1. Department of Labor a Industries, Division of Asbestos and Leed Enforcement
100 Cambridge Street, Row 1106, Boston, MA 02202 FAX: (617)727-7563
2. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, NA
Occupants of dwelling unit
All other occupants of the residential premises, if any
Local Board of Health/Code Enforcement Agency
3.
4.
5.
6.
Massachusetts Historical [omission
220 Morrissey Blvd.
Boston, MA 02202
FAX: (617)727-5128
l 5b - %V\O
02130 FAX: (617) 483.6931
(617) 522-3735
(if premises are listed on the State Register of Historic
Places, this notification scut be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
initiating preventive deleading)
D*LEADING 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, 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 best of his/her knowledge and belief.
Date V"dvt A i5 \\D‘YeR14 Signed ":24 (9. l2 7.
Company Name: \'4vvt.
pp
Telephone Number: li\?-5a-1-' J\\0R,
lb r_
NOTIFICATIONS SHALL EE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL RE RETURNED BY D.L.I.