127 Notification of Deleading 1997 RCM : r
oak PHONE N7. :
olik Sep. 23 1997 08:29AM 191
I)cparOUcnt of Public health coil Dcpcciiocci ul LcLor l I++d
Contractor performing prof
Lead Paint Inspector
NOTIFICATION OF I)El.EA DING WO!:I:
All sections of this form must be c'oungf.cted mine + U en
witfi the Pnitfctlion requirements ,tM (i L C. III 8 I
NIIVn1-
If low-risk deleading work is being performed,complwe the following line;
Property Owner
AAdresa of Project
Building Name(it any)
Street Address
City
Deleading Method:
11 l r 11.7
SEP 2 3 1907
license t ? /no 7
Exp. Daic Zest.4-.7 j-97.
License NL� // Y ?
Date of Inspection L5'i.^97
Agent(s)
If"Other-selected, please explain
Check One: dwelling is multi-family
single-family
Stan Date /l/' n.7 ../.99 7 Completion Darn 7} .' '% / ! 7
Whet will work be done:
Project Supervisor's Nam
Property Qwtgr /!//i/✓L
Add L
City
Tekpttonc
Lee'
�� '�iiii-sera:
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weekends/
mord
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In case of emergency coma
Phone: dry(
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License II/9C /O c3 7
dir / /eitt,
S ntc
1.GC..< Zip LZ/dL R C7
(OVER)
ROM : a 1
in. ... udarmc wide t.lmsnt
mctlaxl(s) of removal or CPVCnnt: of I
and 'uuvt Ire rcecivc..1 by the loIk ry
a PHONE h6]. :
olik Sep. 23 1997 00:29RM P2
pct C. I IIl/, .t$4 (;M@ )2(kl and I 0 CMR 460.0(H), notice of the date ants
'.r n:miter accc sibte m:acnnk; ennui:dng Onnperom levels of Icad is to be provided
at Hastert: (LW d: va print in the bcgiuning nfdcicnd(ng.
)ccuparns of tlnl (1.vrltiuir oar
2. All otbcr occupants of d:c restdcu(iai prctniscs, if any
3, Director, Childhood had Poisoning Prevention Program. Fats C617) 153-8436
Department of Public ticaith, 470 Atlantic Avenue, Boston. MA 02210
4 Director,'Asbestos and Lead Program
Department of Labor and industries
Room 1106. 100 C:unbriage Sncvl.
uoston, MA 02202
Fax(617)727-7568
5. Local Board of Healtil/Codc HnIO(eement Agency
6. Massachusettt listorical Commission.. (If premises is listed on the State Register of Historic Places, this notification
220 Morrissey 15Ivd must be made upon receipt of an Order To Correct Violations or at least 30
Boston, MA 02125 days prior initiating preventive deleading.)
Fax (617)727-5128
DeieadingInntractnr
The undersigned hereby states, under the pains and penaltiespf perjury. that he/she has read and understood the Commonwealth
of Massachusetts Deleading Regulations, 454 CMR 22.00.sdnd .. •.t +ning Pr;:lion and Control Regulations, 105 CMR
460.00 and that the information contained in this notifi an is I :nd car „Der the best of his/her knowledge and belief
Due 9-0z/- / 7 Si:. _ / < e%
ale:
Company .ft,
Rronertyi1wner(If owner or unlicensed owner's agent will be preforming low-risk delcding work) m:r
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead Poisoning Prevention
and Control Regulations, (05 CMR 460,175, for owner/agent low-risk abatement and containment I further certify that I or
my agent win bc performing the following low-risk activities(I have circled all that apply): -
applying liquid cneapsulan[ capping baseboards
applying exterior vinyl siding covering surfaces
removing doors, cabinet doors.,shutters
I certify that all the information contained in this potilieation is true and correct to the best of my knowledge and belief.
Datc• Signed•
+ntstv.alNllnnvt
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UiLNOTIAW Rev 1 ?S