46 Notification of Deleading 1997 batement Solutions ia PHONE NO. : 413 535 0197 Si, Jan. 23 1997 05:51PM P1
L.ead Abatement Solutions. Inc.,-
Fox Cover Sheet
om:
JAN 2 7 1997
03 v:A?f,PicN BOARD OF HEALIY
fax#: (52/9-3i0210
P.O. Box 1712
Westfield, MA 0108G-1712
fax (413)535-0197• phone (413) 535 - 0197
Awe
CONSIONWEALTB OF MASSAi_-sOSETTS
Department of Labor i industries and Department Of Public Health
NOTIFICATION OF DELEpDZNG WORK
with the awn-Sons raqulrretet w a.LL..4.121 s 1�1Y
rar Qat 11.00 and 103 CNR 460 000 is most recently amended
Contractor peAoaning project
PI er6EK:_ •
LE
mW 33Ji a
viMCY USE)
Ste.
License # .. g
Exp•date_(_/ 7
f Ln � . License N 1 a 57 5
Lead Paint Inspector' A % - .I( C /
/A/bt'(UI Gh 44/Lbire �' ate of Inspection 3120197
If low-risk deleading work is being performed, complete the following line:
Property owner_ / /f=
Address of Project
or"`Dt Floor _
Building Name (if any) .
L i iy '£�l' 1 S f, Apt. No
Street Address (%n COP.
city 11grIfiF;MF
of
neleading Method: (get/Dry/Dry Scraping") Heat Gun . Caustics�—
.C-emolitioPT �Replacemen� Other
Li quid Encapsulant CCOVe r3pg7
If "other" selected, please 'explain
Agent(s)
Caeck One:
Start date
h a q i Completion date "With X1.3 fig/
/
When will work be done: A.N.
E.N. Weekends?
cense
duelling is multi-family
r
single redly
Project Supervisors name
Property Owner
Address
city hind+ .7u0. to^
Telephone 1113-5g10 '^+" L)
■
In case of emergency contact
Phone: day 636'O(47 /t
(over)
State It {�
Zip /)JO &()
:d Wd2S:S0 L66T £2 •uef
LETO S£S £Th : 'ON 3hOHd
suo)yn(os luawalpge pea? : Wc?J
in ..ccordanae with MAidlk assachusetts oenetal flawS C. 11: s 107 41^'2.00 and 105 CAR 4E0-000 notice
of the data and metnoca(51 of removal ac cov ring of paint, Piaster o other accessible meter
containing dangerous level- Of lead istto egl provided( and a mumust
tghe redeivad he the-following
re-CSC/no, at least t ( el d s Pts0
Occupants of the awn:ling unit
A1: other occupants Of the residential premised, if any
gram Fax (6141 753-6416
Di nectar, Childhood LHealth P470 ArlantiCAvenue,Y BOecon, VA 02110
Department Of Pcbl i� Health,
Direct04 Assbestos & Lead Program
Department of Labor a Street
Root 011006. 02202
0 Cambridge.
Loral 9eard of yealto/code Enforcement Agency
Massachusetts Historical COrmissiOn
220 Morrissey Blvd.
Boston, MA 02125
Fax 15121 127-7568
Of premises is Bete"h on noel StateiRe9iss[r(,
Of a HiStoric r Planes, Order to Correct
Viol upon receipt att e[ to Or
Violations or at least a days 1 print- to
,naC Jr i.':y pcevpntivn. d Faxa 161 1) 72/-5110
Deleadlnd Contractor
The undersigned hereby. states, under the pains and penalties of perjury, that
he/she has read and Understood the Commonwealth of Massachusetts OP-lading
Regulations, 454 CMR 2=.00 and Leading Poisoning Prevention and Control
9egU),atidns, 105 CMR 4E0,000, and that the information contained in this
notification is true and correct Co the best of his/her knowledge belief.
Date ! 1aj .4V-- Signed: _ i, 7
Title.
■
2ornany.
Property cxaner (If owner or unlicensed O'-ner'S agent nn.1 be performing low-Sisk delenein9 wo Ckl
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
further certify that S or my agent will be performing
the following low-risk activities (I have circled all that apply) :
capping baseooarcis
covering surfacer
applying 1ialId en;a4aulent
applying exterior vinyl siding
removing doorn, catty net doors, shutters
I rectify that a' 1 the Information wonr,Lled In this nnti(icat:on
he Of my knCwlecgq And belief.
(late:
PP; 10;12/95
d Wd2S:S0 LEST 22 Supt
Signed:
L6T0 SES LIP : 'ON 2N0Hd
suonintos luatlaTPgb peal WON