106 Deleading Notification 2009 Department of%atblic Health- Child}wod Lead PoisoniSrevention Program
Deleading Notification
zee complete all sections of this form clearly.Incomplete or illegible forms will be returned.
ad Paint Inspector.T/jn's ✓L!ONiEise•9 .:
tperty Owner /,/Lr,veg ,C32..,.�.,✓
tperty Owner's Address./61 Ada"/.5./ /°04Zs.
License#MR /Y30 Inspection Date S- 22-ay
jEta; M_,s
Zip Code 01053
thorized person performing work //e,1 e y .R w-✓ Lic#/Autlr# /Oj;2 es-OM
dress of authorized person 7e /sJA,"v.: erYpl- M9 Zip Code - e) o 5 3
lephooe Number Y/ 037-//t 5'
dress where the work will be done:
Ming Name(if any) Floor / t L
eet Address /C E i4/Are2c S r Apt No._
y L.EFD> Zip Code p/cs-,j The property is a ✓mglti-family
leadat Methodts):
king paint intact(high risk)
minim
aping
mponent removal/replacement
tying
o Making paint intact(moderate
risk)
❑ Liquid encapsulant
of Covering
❑ Capping baseboards
single family.
o Applying vinyl siding on exterior
❑ Component removal(low risk
components)
❑ Other
s work will begin on rp/4JO/fand will finish by 4/$/ 'jThe work will be done in the am pm or • weekends.
'ase of Emergency Contact iiC 4t y f z0w,y
ytime Phone y/.3 .6-3 -//(35. Evening Phone 40.3 ,53.7-c 7W
operty Owner must complete and sign the following information:
that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning •
ion and Control Regulations, 105 CMR 460.000,will conduct deleading work.I further certify that the authorized
s)will not exceed the scope of his/her authority and will be performing only those activities indicated above.All of the
Rion contained in this document is true and correct to the best of my knowledge and belief.
e %j( - O.2
Signed
following people/agencies must be notified ten days before beginning work:
:upants of the dwelling unit
other occupants of the residential premises,if any work
Idhood Lead Poisoning Prevention Program,DPH . Fax( .r4-6700
/RHO
andolph Street,Canton,MA 02021
estos and Lead Program,DOS
itaniford St, Id Floor,Boston,MA 02114
al Board of Healtb/Code Enforcement Agency
•If the home is on the State Register of Historic Places,call the MA Historical Commission at(617)727-8470.