32 Notification of Deleading 2000 ")"ili it t
Depai.ment of Public Health/Department Of Labor d istr i es
NOTIFICATION OF DELEADING WORN FILE NUMBER
ALL sections of this form oust be cmipteted in order to comply with
the notification requirements of M.G.L.C. 111 4 197,
454 OPR 22.00 and 105 CPR 460.000 as most recently amended
Contractor performing ` S ,project t4\ . .Nib License #t�.�'{q�Exp. Date .-a. \-aC3C
N
Lead Paint Inspector ts'a. S?1cpca' License S r•\�- 4,
PROPERTY OWNER (If owner or unlicensed owner's agent will be performing low-
risk deleading work,
complete the following ):
Property Owner Agent(s)
Address
Telephone Number
1 ,1111111E 11
n; Ftl11 J [lRU
7
NORTHAMPTON BOARD OF HEALTH
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 DIR 460.175, for owner/agent low-risk abate rent and
containment. I further certify that I or a)' agent will be performing the +-following low-risk activities (1
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 OF PROJECT:
Street Address t vN\",e SApt-t-Number
City N `i ASV-I',xt cC';n
Zip ri,\MGG
PropertyOwner C \- /+e-
Telephone Number
Address 'a'T t(\\.\\\
At
Deleading Method: Wet/Dry Scraping Heat Gun
Demolition Caustics
Covering') Other
If "Other" selected, please explain
Liquid Ecapsulant
(iSeplacemeJ
Check one: dwelling is multi-family single-family
other
Page 2 of 2
Start Date
_ "\ -Cr) Completion date `a -..\D"-C-ie%
When will work be done: am_jP'J pnki`tC45pecify times on site) Weekends? ht -
Project Supervisor Name License#OC.\ ■c? Exp. Dated-We, -ACSA
-�\_�q%Cj t�' L Carrierl\vx'\�
Workman's Compensation Policy Number a
In Case of Emergency Contact: \t t�4\ ,\`t&\V (Contractor's Representative)
In accordance with Massachusetts General Laws C. 111 §%97, 454 CPRe22.00eandb105meR 460.000,containing
of the and
date and method(s) of removal or covering of paint, p at taint g
Business days prior toad the abeginning of deleading.t NOTIFICATIONS following iBE TAXED. air to be provided and dangerous levels of 1. Department Industries, of Asbestos and � 8
100 �idge Street, ROOM 1106, Boston, NA 02202 AX617)727-7568
2. Director, Childhood Lead Poisoning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617)
6(61 )2983-65 983-6931
Occupants of dwelling unit
All other occupants of the residential premises, if any
3.
4.
5.
Local Board of Health/Code Enforcement
Massachusetts Historical [omission
220 Morrissey Blvd.
Boston, MA 02202
FAX: (6171727.5128
Agency
(if premises are listed on the State Register receipt Places, this notification mast be made upon P i to an or Order To Correct Violations ore at least 30 days prior to
initiating preventive
DELEADINC CONTRACTOR:
The undersigned hereby states, under the pains and penalties of perjury, that
he/she has read and understood the Commonwealth of Massachusetts Deleading
regulations, 454 CMR 22.00, ant 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 his/her knowledge and belief.
Date 'Vs'T 9,-� �, ` Signed
vt'
Company Name: We. C- NPi�'t�
Address: 1/4NAG-N9 .74‘Sh.�
Telephone Number: a%\'1 ' (Na:1 , -CSV c)
NOTIFICATIONS NNOTIFICATIONSWItHILLLL5NOT BEACC0EP1141 RED WILL BE RETURNED BY D.L.I.