49 Notification of Deleading 1999 J'(N 2 1999
~OMMONWEALTH OF MASSACIONSETTS
tment of Labor 6 Industries and Department of Public 1!e
NOTIFICATION OF DELEADING WORK
11 sections of this form mutt be completed in ordor Co comply
wath the notification requirements of H.G.L. 0.111 5 :97
454 Qqi 22.00 and 105 C2,a 460.000 as most recently a.'ncn_o_
PILE NTflER:
Contractor performing project J 1/ / �.,[il�n,°� License N �CL'�J/�:
Lead Paint Inspecto
low-
Lice's
ade PO- _nE ores
deleading work is being performed, sympi et
nt ',
owner
Address of Project
_ t:_dtry Name (1f any)
_ u Oct Address 4/ 9 Vfikiwyount
Deleading Method: Wet/Dry Scraping Ileac Gun
:u d Eneedpsul am o;;77 ng emoliCon
ce r' s elec ered, please explain
a J”_e La_
rPcn: / -t 2
Compie':ior. Cate
be done: A.M. 7 P.M.
upe:visor ' s name /Z g l((/ !'
nor U� =_ Fe ? ey
ess /d gfriiettir S.1
:.ase at emergency contact
s:_,re Tait,
1422 L cc. ec/
•
(ever;
C7/" 2
oiaCo
• �ce with Massachus.._.s General Laws c. 111 4 190 CMR 22.00 a 105 CMS 460.000 notice
aa methods(s) of removal or covering of paint, plaster or other accessible mates tabs
angaeops levels of lead is to be provided and must be received by the following
least ten (10) days prior to beginning of deleading.
I,o dwelling unit
[ the residonti al premises, if any
nn � adin9 Poisoning 'revention Program Fab (01 4) 153-u4v
n .1 lv raj h, 430 Atlantic Avenue, Boston, MA 02110
.- - - Asbestos 6 lead Program
sown[
ot Labor a Industries
...o.n .J■06, IOU Cni<ltice bvvnt
Delgada:). Contractor
Comsat s..un
Agent
Fax (6111 727-156b
(If premises is listed on the State kegister
of Historic Places, this not i fiaac ion must b.
made upon receipt of an Order to Correct
violations or least 30 Jaye in :c. tic
Ini tiatii19 preventive deleaci.
Fax (6:71 ..L
:e/ undersigned hereby states, under the pains and penalties of pert u_y, that
sha has read and understood the Commonwealth of Massachusetts Deleading
Reguia ions, 454 CMR 22. 00 and Leading Poisoning Prevention and Control
Roggl3_ions, 105 CMR 460. 000, and that the information contained in this
_ fic.)tion is [rut and correct to the best of his/her knowledge and belief.
F Lr Ur/key L t rnoc)2JCL
��„a�,y�lvhn /
caner n agent will he performing low-cist smieruclig poi ...
ce_t i_, that I have complied with the training requirements of the
Cormronwealth. of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 460. 175, for owner/agent low-risk abatement and containment. I
LDrtiier certify that I or my agent will be performing
following low-risk activities (1 have circled all that apply) :
Capping has el) ,a,.0
covering
Hw.l Lr tel:: nnti[irat:on is t, n. ..n,.•