178 Deleading Notification 2001 VF
JUL - 3 2001
Department of Public Health/Department Of Labor & Industries ' -
NOTIFICATION OF DELEADING WORE FILE NUMBER
ALL sections of this form gust be cmpteted in order to comply with
the notification requirements of M.G.L.c. Ill § 197,
454 CMR 22.00 and 105 DV 460.000 as most recently amended
Contractor performing projt
i1�� ec Lieense #j�1�V�-Exp. Date�-',yam,.- a
Lead Paint Inspector 1::\\N a E]. j t &se. License flalay
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner
Agents)
Address
Telephone Numbe
1 certify that I have coaplied with the training requirements of the Coatnnwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 OR 460.175 for owner/agent Low-risk abetment and
containment. I further certify that I or ay agent will be performing the 4-following low-risk activities (i
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
I certify that all the information contained in this notification is-true and correct to the best of my
knowledge and belief.
Date: Signed:
ADDRESS OP PROJECT:
Street Address \1F, \\ C:SdSfet
ice'v Apt. Number
City t �j1
Zip 0*-:`aiCM
Propertyowner C ?- 1st Address —`- )\ -& �p� ,
Telephone Number '\ �1C�iG�,�ay� G\L.:VC
O
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Liquid Encapsulant
Covering Other ce
9 Other L Replacement')
If 'Other" selected, please explain
Check one.
dwelling is multi-family single-family
other
1
�t Page 2 of 2
Start Date 1 -IR{j\ Completion date -\G'C\
When will work be done: am Ll pm4_AA Specify times on site) Weekends? \lG
Project Supervisor Name \ 'F'"1\hC - NCR)
Licensefik\\k2 Exp. Date‘'s■-c •l:
Workman's Compensation Policy Numbers .\O�.gFt�fia.G\VA. carrier
In Case of Emergency Contact:1[a(Contractor's Representative)
-3\\a'f,
In accordance with Massachusetts General Laws C. 111 5197, 454 0(R 22.00 and 105 CMR 460.000, notice of the
date and method(s) of removal or covering of paint, plaster or other accessible materials containing
dangerous levels of lead is to be provided and eat be received by the following persons, at least ten
business days prior to the beginning of deleading. NOTIFICATIONS NAY BE FAZED.
1. Department of Labor E Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Roma 1106, Boston, MA 02202 FAX: (617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program 6Vjb
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617) 983-6931
(617) 522-8735
3. Occtgets of dwelling unit
4. All other occupants of the residential premises, if any
5. Local Board of Health/Code Enforcement Agency _
6. Massachusetts Historical Commission (if premises are listed on the State Register of Historic
220 Morrissey Blvd. Places, this notification mist be made upon receipt of an
Boston, MA 02202 Order To Correct Violations or at least 30 days prior to
FAX: (617)727-5128 initiating preventive deteading)
DELEADING CONTRACTOR:
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deluding
regulations, 454 CMR 22.00, and lead Poisoning Prevention and Control
Regulations, 105 CMR 460.000, and that the information contained in this
notification is true and correct to the best of e/h a and belief.
Date NO -aS-C\ Signed i -(
Company Name:
o Ne'Nc-
Address: c :&N.1 .1t.c. 1'St., +-% Bm4 N c-tc-olx
Telephone Number:
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.