14 Deleading-notification Nov 15 2024 workDepartment 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__________________________ License #_______ Inspection Date _________
Property Owner______________________________
Property Owner’s Address_____________________________________________________ Zip Code______________
Authorized person performing work:_______________________________________ Lic#/Auth.#_________________
Address of authorized person______________________________________________________ Zip Code____________
Telephone Number (___)______________________
Address where the work will be done:
Building Name (if any)__________________________________________Floor________________
Street Address________________________________________________ Apt No._____
City______________________ Zip Code_________ The property is a ___multi-family ____ single family.
Deleading Method(s):
Making paint intact (high risk)
Demolition
Scraping
Component removal/replacement
Dipping
Making paint intact (moderate
risk)
Liquid encapsulant
Covering
Capping baseboards
Applying vinyl siding on exterior
Component removal (low risk
components)
Other:__________________
The work will begin on __/__/__ and will finish by __/__/__. The work will be done in the ___am __pm or ___ weekends.
In Case of Emergency Contact________________________________________
Daytime Phone__________________________ Evening Phone__________________
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.
Date_______________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
CLPPPLeadInspectionReporting@mass.govMWRHO
5 Randolph Street, Canton, MA 02021
4.Asbestos and Lead Program, DLS
19 Staniford St, 1st 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.
Contact BOH for Fax or Email
or email: