17 Notification of Deleading 1998 COMMONWEALTH OF HAS: 2HUSE
Department of Labor b Industries and Department o
NOTIFICATION OF DELEADING WO
Ml section. of this form must be completed in order
with the notification requirements of M.G.L. ell
454 QN 22.00 and 105 QIX 460.000 as most recently
NOV - 9 1998
to 5omply
1N@WFlT AMPTON BOARD OF HEALTH;
FILE NUMBER'. (Af.EIICY USE)
contractor perlonning project , j/Jh/-) (?>l1/tney License M CGY 76, /
Exp.date47 I
Lead Paint Inspector7,00/tre Zoe—Lieense qr.�.�SU
Date of IuspectIC
If low-risk deleading work is being performed, complete the fall nwinn
. opLe t ty owner / ((-1
Address of Project
Building Name (if any) y� / Floor
/' 1 `'y
Street Address / 7 p rf(f �Sa 3pf7 Apt. No.
/qr.) l�a /724 Zip o /0(00
Deleading HethoJWet/° ScrapiEa Heat Gun Caustics
Liquid Eocapsulant Covering <emoliLion ( cplacenm;:_l
II "other" selected, please explain
lu.iuny ,s m
aris ly di.de r..,,,, , C-i
rt date /"6/ _ / 7 Completion date 7✓0 V /
Waeu will work be done: A.M. P.M. tri Weekends'
reject Supervisor s name Col Eh2 F1 (tat I, c..., coo 7(n (1
:..perry Owner - 7 ( e4- 16b. S
Address / 9 72Z 4f CfG VOL/ S .-- _._._ .
City /%iVho/272A.47 State zip 0/4)60
'telephone
To case of emergency contact _/»hn F t ea �-/
215 Pomeroy Meadow Road, Southampton, MA 01073
Phone day V/3 So\-7-FOS ever5Ing Vi3—�1i2ZJ )ard,
(over;
at 105
ndauce with Massachusetts General Laws c. 111 4 191 GI plaster. 00 a other 1Ra 460500 mnoticels
Jai e and mnthods(s) of removal or covering of paint,
lnp ding±roes levels of lead is to be provided and must be received by the following
ast ten (10) days prior to beginning of deleading.
the dwelling unit
r cater tits of the residential premises, if any
ni lJhood lama di ng Prviacning Ple entinn Program 02110
.rt Pulnl i� Health, 470 Atlantis Avenue, Boston,
Uri. ler, Asbestos & Lnatl Progl. r
bep,talent oP Labor c I ndn St Lees
n,on6, 100 carm.t;.Jqe a 1.
u„� dadoa
220 tbsoriesro 01
r n. MS 02125
11/Cnd.: eni n0 e0•me tit
Fax 1617) 153-94 'f
Fax 1611) 727-7568
cal cormni ssi.+n 11( premises is listed on the State Re aster
1 of Historic Places, notification
s
made upon receipt of an Order to Coect
Violations o at least 30 days print to
initiating preventive deleadiny)
tax 16111 7:7-'.12:'
Deleading 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 CI4R 22.00 and Leading Poisoning Prevention and Control
Peguiations, 105 CMR 460.000, and that the information contained in this
r.0 .i ficdtion i5 true and correct to the best of his/her knowledge and belief.
Q
Title:
--' f f Le 11'1-- iltf2U
Property owner (Il owner of tmlreenaed owner's agent will be performing low-risk deleadinq a,ou_
I certify that I have complied with the training requirements of the
Commonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 CMR 460. 175, for owner/agent low-risk abatement and containment. I
fu rarer certify that I or my agent will be performing
the, following low-risk activities (I have circled all that apply) :
,11,I , iv] °. ■■1 1id . r.-a._m a�n
..rl., . ra "rl.••Aril v uyl .]ding
• lid,'10.11 Ohli son l ,01, t
capping Lasehoards
covering stir fa. . :
tification is c