6 Asbestos Notification Form 2000 4C0030
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COMMONWEALTH OF MASSACHUSETTS
- THAMnON MD OF HEALTH
t of Labor F. Industries and Department of Public Health ---
P. 2
;., J.. iS y@ i 0lly�S
NOTIFICATION OF DELEADING WORK
sections of this fore meat be ooasted i n,dnr to comply
i y the notification requirements of H.G.L. c_ill S 197.
54 UR 22.00 aad lOS QOt 460.000 a0 mtt recently canned
FIfE minima:
Qppp
Contactor liedonninq project ABIDE, INC.
(AGENCY USE)
license p 1?C041612
Exp.date August 31 , 20
Lead Pai4t Inspecctor AA (kK HA-IA/ES License I I IgCA
If low-rysk del ding work is being performed,
Property owner . E FaIT gnASES Agoutis)
Date of Inspection t2/3UJft
complete the following line:
i4t31oc-
Address f Pro' - t
Building Name li any) Floor j S-r
Street Atcdres5 £ V]i,A Cjy Cc 3,1,7T-
C V Apt. tie. R1/2C,t41
JULL2mAinV"TON Zip GtOCoO
City
Deleadini Method. Wet/Dry Scraping Heat Gun Caustics
Liquid Pocapsul {Lit Covering Demolition Replacement
If "other selected, please explain SOK r L\CctLJ (2 ) wtfkiow
Inc( cfrens, t)enec. W %Nese (2_-)w 4Jcm ->
Check One:
w4 fang 4s eWti-f>mily V single family___ ,.
Start dale ' ZSJW
Completion date
When will; work done: A.M. '7',w 7,;LO Weekends? NO
Project luPervisbr's name
Robert P. LaMountain License fl [253605
e( \Sc5 (SUCK- `]oWLGS�
Property fawner i X G FtiZ•
41°
Add rocs
City
MAIN STRAiliT
tan/ state Me
SroG - 2t
Tel :9$
In case of p.mergjncy contact
Frank
Till`; , President
Zlp OICXIQ
Phone da!y 41 . -525-0644 even ng 413-525-0644
lover;
1-14-GOO M.20VM
1-utx4 48111E INC 4135950878
In accntdancnl with Ma acnvzetta General Lars c. 111 4 101 CHB 22.00 ano 105 OIR 460.000 notice
of the date *d meth is) of removal or covering of paint, plaster or other accessible materials
containing dgnoMrous 1 gels Of lead is to be provided and must be received by the following
persons, at beast ten '(10) days Paiet to beginning of deleading.
•
1- Occupant. of the a aping Whit t-`WN ante SARAOA S�AAN1- 1
I CO'sete. 413- spa-soltJ
2. All othe1 o Cupan4t of the residential premises, If anyC /OrieDIJ y IC-6)
1
J
3. Director, Childho4l Leading Poisoning Prevention Program Fox (6111 753-9436
Departnwnt of Public Health. 410 Atlantic Avenue, Bolton, HA 02110
•
4. Di rector.II Asbestosi 4 Lead Program
DepartIttit of Lab& a Industries
Rope 110116. 100 Cridge Street
Roston, a+n 0$202
5. Local Board of He
6. Massachudatts His
220 Horr25sev Blv
Boston, )k 02125
standing Coijtradtor
filth/node Enforcement Agency Ire At�
.000 fJot 1Anef40W 93fr& O
torical Commission at premiss> is listed on the State Register
of Historic Places, this notification must be
made upon ons receipt
ofs anJ O days Order to Correct
vadea up at prior to
.na. ...g preventive deleadino)
Pas tell) 127-920
fax lane 211- 0726
rAx (4131587-1124
The undersigned h
he/she has read a
Regulationp, 454
Regulation, 105
notificatipn is t
Date 4 1 c __
reby states, under the pains and penalties of perjury, that
d understood the Commonwealth of Massachusetts Deleading
R 22.00 and Leading Poisoning Prevention and Control
R 460.000, and that the information contained in this
ue and correct to the best of his/her knowledge and belief.
stenerniii_kri_ Frank T411 1
emt
Title: President
Com0any: ABIDE, INC.
Property Owns (If owlet or unlicensed owner:. agent will be performing low-rise delete
I certify that I
Commonwealth of M{
105 CMR 461.175,
further cep-tify t
the following low
g work)
ave complied with the training requirements of the
ssachusetts Lead Poising Prevention and Control Regulations,
or owner/agent low-risk abatement and containment. I
at I or my agent will be performing
risk activities (I have circled all that apply) :
1 ng Siqu encapsulant
app) ing mete int vinyl siding
reno4tng door , cabinet dtors. shutters
Capping hasebOarda
covering Surracns
I certify hoTt all th inL>r.atlon contained in this nouucat ion is n Tim and coa.ert t.. the
best of my egowledge Ad belief.
oars:
sCW3c
REV In/12/951
Etgoed.
P
1—IA-200 S: 1SFM
DATE:
ATTENTION:
FAX NUMBER:
FROM:
REGARDING:
FRUM ABIDE INC d135250678
a b i d e
Abide, Inc., Environmental Contracting
FAX COVER SHEET
Svwc(2.-c LiMWN JAVA)
G 5 I1 CW2T1 wtAtoviti eeCN
NUMBER
COMMENTS-
OF PALES
(Including this one): 3
`(Zi : FAX
jD,Re
Toe.. C>_ff all -75 % 84?
tt12E
To CC LEAt-s C2u(32AA4 G1? - 17 6'7
I}y,2CtilNsA
N WA-R-fl HE At-..'S tj N,V3 587 ' t
MA-64
yt NE.` f ECS 4l3 -7R9 21
If there art any pr
Cunllemfppy, me The
Information trap AYde.Inc
not the blended recipient,
ptnhibittd. If ypu have ramf
PC)
Phone 4 3-52513644
blems receiving this transmission, please call 413-525-0644.
eon arcomp+nyiag lids Canopy transmission racy ma nn enanle and privileged
Ilia intarnudimt is Saida to by for the n'c or the addrvN Individual or entity. Ryon on
mart that pry dbclosmc,copying,dbbfbeaan or nu oldie mamma of fhb transmission Is
ed this tnmm.Wbxt In enor,phone notify m by tckphoo.Ims.aM ly.
Box 886 East Longmeadow, MA 01028
• Fax 413-525-0678 • E-mail ABIDEI @aol.com
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