40 Notification of Deleading 1995 In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 §197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(e) of
removal or covering of paint, plaster soil or other accessible material containing
dangerous levels of lead, is to be provided to the following -persons at least five
days prior to the beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street,. Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
- 5. Local-Board of Health/Code Enforcement Agency -
6. Massachusetts Historical Commission -- - -----
(if premises is listed on the State Register of Historic Places)
•
The undersigned hereby states, under the penalties of,perjury, that s/he has read
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CX?
22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and
;.hat the information contained in this-notification Lion is true and-correct to the best
of his/her knowledge and belief.
Date 2. Signed: A ea, /
�c7 �y Title:
At : Am/V'�// Company: ar/ a
Address: (/�T//J � r Afj'-7r6
Telephone #: / — ///
Office Use Only
•
•
•
fi . . .
0034B/6 • rev_12/05/90
v
DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR a I,
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to
the notification requirements of X.G.L. C..111
PILE NUMBER
Lead Paint Inspector 'g7/ Date of. Inspection
Contractor performing project 4 27C6 rd./75T License # 00//070
Address of Project
Building Name (if any) Floor
3//7/5--
Street Address
City
J ( '
Apt. No.
Deleading Method: DRY SCRAPING HEAT GUN ENCAPSULATION- DEMOLITION
(circle all that apply)
POWER SANDING CAUSTICS REPLACEMENT OTHER
If "Other" selected, please explain
Check one: dwelling its Multi-family single family L�
Start date y/ 9 Completion Date 61/C//(.0
7670 7:0 6
When will work be done: am /0:06 pm p;pn weekends?
Project Supervisor Name (/ )c/ 206
Property Owner
J o 9rc 7 14.CE
License # 00//090
Address /Se 1/9/7///, /PA )�
City 077/ /71g//,1)/ / / State 7777/Y
Telephone 4/73 fcfV & 5%nAD
In case of emergency, contact what person:
Zip O/4 6
7312Fg40,42 i-/t?c ?cam
Phone: Area code required day h(/3 5c7-37/7 evening
(onn)
0034B/3
rev 12/05/90