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260 Notification of Deleading 1997 COMLONVWEALTH OF MASSACHUSETAi Ir I _ Department of Labor c Industries and Department 'e£ Public, I`p!' NOTIFICATION OF DELEADING WORK �: JAN 1 4 1996 ;i J All sections of this form most be co plated in ostler to comply with the notification rsgOir®eftJ of M.0.1.. c.111 5 197, 656 OQ 92.00 and 105 Cla 660.000 as most recently amended ;PoORTHAMPTON BOARD OF HEALTH TILE 102941: (Tcncr ) Contactor performing project License * Exp.date Lead Pain inspector 57C-711 IC✓ !yarRQ.S License 4 T ) 3 i k Date of Inspection / /t) 5/9 . 7 if low-risk deleading work is being performed, complete the following l�ine: Property owner Agent(s) ,e,e$ t F / '/?/Ynd94f/ t C N "y I'M e2fif-S -.Zile Address o£ Project / I p p .L Building Name (if any) L la P a 5 L/, LLQ f C (�! fS Floor / AA /1 LIn�II Street Address `© A, /1 /`'�(.7'/ n S , Apt. No. H A - `/6 t c ,..uItfr7( zip 0 /r9 5-,3 City Lae eels Mass Deieading Method: Wet/Dry Scraping Heat Gun Caustics Liquid Encapsulant S Demolition Replacement Other If "Other" selected, please explain Check One: dwelling is multi-family V single family 3 199 % Feb /0 195' -7 Start date he /D Completion date When will work be done: A.M. Yf-3 P.M. yes Weekends? /L/C! Project Supervisor's name / License # Property owner I e E(.'1 .� j1-�-fi 1-`ncje /3-55- 0C lgtr 5 Address 667 /,da/n p) / ✓ /��J l City tiU!yid q9.5-0 h � state Mg 5 Zip ( Y/ Q Ld Telephone >c'- 4 In case of emergency contact Phone: day 536 Pis 6 Ceot; e Jcpenou/5)4;; (] evening -1 J-/0 7 ih (over) me with Massachu[,ntl era: Laws c II 5 .197 47134 ∎:-nn sq,y;u> CM“ 4f•J.00u notice of the date and method,(.51 of ^14ni en covering r• paint, oldster or ^ut a -rlb:e materials c:talning dangecaus ' vets of .<aC is to be provided and roust n .e.ei . .J by the following Persons. at leapt tan (101 -tlaya pries to beginning of do:siding.e v. :LDant? of the Welling unit 2. All other occupants of the residential. premises, if any 3. DirCetor, Childhood Leading Poisoning Pcevonrinn Program Department of Public Health, 470 Atlantic Avenue, Boston, MA 02110 4. Director, Asbestos c Lead Program Department of Labor C industries Room 11006, 100 Cambridge Street Boston, MA 02202 5. Local Hoard of Health/Code En'orcerent Agency Massachusetts Historical commission 220 Morrissey Blvd: Boston, MA 02125 Deleading Contractor Fax (G17) 753-8436 Fax (617) 72?-7562 If premises is listed on the State Register of historic ?laces, this notification must be made upon receipt of an Order to Correct Violations or at least 30 days prior to initiating preventive deleading) Fax (617) 727-5123 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 QAR 22.00 and Leading 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 Signed:. Title: Company: Property Owner (If owner or unlicensed owner's agent will be performing low-risk deleading work) 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 I or my agent will be perfcr.,anc the following low-risk activities (I have circled all that apply) : applying ligLid encapsulant applying exterior vinYi siding removing doors, cabinet doors, shutt9Ls capping baseboards overing sur:a Ces I certify that all the information contained in this notification is true and Correct to the bear of my kna+leege and belief. Date: REV loo'/e4 c7L1li_0`19 97 r, Aid,t4emamt 54°1 / � 69 Suffolk Stre Holyoke, HA 01060