48 Oak St. Delead Notification 4-30-19Department of Public Health - Childhood Lead Poisoning Prevention Program
Deleading Notification
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned.
Lead Paint Inspector 7cvV i ct '(3, f 'f ss License # 2 `) Inspection Date 6i/' -s / 9
Property
Property
Authorized person performing
Address of authorized person_
Telephone Number'3l3 lac
Address where the work will be done:
Building Name (if any)
Street Address A 1 C r -
City U Q f -ON 4,11
Deleadina Method(s):
Apt
Zip Code C4 l 0Z Z
Lic#/Auth.# 3 9 i 1 Lq - jVM
Zip Codey t es G Z
Zip Code o t 0 6 o The property is a x multi -family _ single family.
❑ Making paint intact (high risk) ❑ Making paint intact (moderate )a Applying vinyl siding on exterior
❑ Demolition risk) ❑ Component removal (low risk
❑ Scraping ❑ Liquid encapsulant components)
❑ Component removal/replacement 1 t Covering ❑ Other:
p Dipping ❑ Capping baseboards
The work will begin on .5-1231 2-� and will finish by: /.32'/2L. The work will be done in the _am _pm or X weekends.
In Case of Emergency Contact Lea tf 05cl ej-
Daytime Phone q/3 2 � a S -o 2 � Evening Phone `i 1:3 Zwc, ?-,Zo
The Property Owner must complete and sign the following information:
I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations, 105 CMR 460.000, will conduct deleading work. I further certify that the authorized
person(s) will not exceed the scope of his/her authority and will be performing only those activities indicated above. All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Date5 f 3 Zu Signed
The following people/agencies must be notified ten days before beginning work: *
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any work will be done in the common areas
3. Childhood Lead Poisoning Prevention Program, DPH Fax (781) 774-6700
MWRHO
5 Randolph Street, Canton, MA 02021
4. Asbestos and Lead Program, DLS
19 Staniford St, 1'Floor, Boston, MA 02114 Fax (617) 626-6965
5. Local Board of Health/Code Enforcement Agency
* If the home is on the State Register of Historic Places, call the MA Historical Commission at (617) 727-8470.