26 APT#3 Notification of Deleading 1999 moRk
u"partment of Pobtic Health/Department Of Labor L Industries
NOTIFICATION OF DELEADING WORE FILE NUMBER
All sections of this form must be completed in order to comply with
the notification requirements of M.G.L.C. III 5 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
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Contractor performing^projectYvV\k\_1`K License 8 Exp. -\ _
Lead Paint Inspector Hntte_ Cc .etc_ License / d ay
PROPERTY OWNER (If owner or unlicensed owner's agent willrba porfrtrming low-
risk
deleading g (
complete the following ): i5j 0 U
JUN 29K9i9
Property Owner Agent(s)
Address
Telephone Number
s_„,,n OEHEALTP
I certify that I have complied with the training requirements of the Commonwealth of Massachusetts Lead
Poisoning Prevention and Control Regulations, 105 CMR 460.175, for owner/agent Low-risk abatement and
containment. 1 further certify that I or my agent wilt be performing the .-following tow-risk activities (I
have circled all that apply):
applying liquid encapsulant capping baseboards removing doors, cabinet doors, shutters
applying exterior vinyl siding covering surfaces
1 certify that all the information contained in this notification Is true and correet to the best of my
knowledge and belief.
Date: Signed:
ADDRESS OF PROJECT: �(�
Street Address alp �7�p {\ t:ILp
City NoS`C."1PN_
PropertyOwnerR1
Telephone Number "\"i-
Apt. Number cD
Zip \s]`o
Address
Deleading Method: Wet/Dry Scraping Heat Gun
(Demolition') Caustics
Covering Other
If "Other" selected, please explain
Liquid Encapsulant
Replacement
Check one: dwelling is multi-family f single-family
other
0014, 00%
((�\ pp Page 2 of 2 (� p
Start Date 1- -\` ll Completion date-I- I\-� 1
1'•36 ` k..GC
When will work be done: am ✓ pm ✓ (Specify times on site) Weekends?�C
�2 ,�t� tCCC\yNM
Project Supervisor Name\ \QV\re.N�4 License/ Exp. Dater\o4-0C
Workman's Compensation Policy NumbertC_C\eteti• WaeXQ CarrierStLLC\Lp/NE\
In Case of Emergency Contact: �u\���•1 VQim (Contractor's Representative) �
%-"%%‘% - -t\%,3%,
In accordance with Massachusetts General Laws C. 111 4197, 454 CUR 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 must be received by the following persons, at least ten
business days prior to the beginning of deleeding. NOTIFICATIONS MAY BE FAXED.
Department of Labor a Industries, Division of Asbestos and Lead Enforcement
100 Cambridge Street, Rom 1106, Boston, MA 02202 FAX: (617)727-7568
Director, Childhood Lead Poisoning Prevention Program 1S3 -Wk\t=.
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130 FAX: (617)983--6981
(617) 522-8735
Occupants of dwelling unit
All other occupants of the residential
5. Local Board of Health/Cede Enforcement
6. Massachusetts Historical Commission
220 Morrissey Blvd.
Boston, 11A 02202
FAX: (617)727.5128
premises, if any
Agency
(if premises are listed an the State Register of Historic
Places, this notification must be made upon receipt of an
Order To Correct Violations or at least 30 days prior to
initiating preventive deleading)
9ELEADINO 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 tad Poisoning Prevention and Control
Regulations, 105 CUR 460.000, and that the information contained in this
notification is true and correct to the best of his/her knowledge and belief.
Date a� .\�SnQ 4, �c�� p Signed
Company N nie: `��''.VL\\ham -`. 1VElTt-', \���`r+aC ddP �-�kc [�.
Address: - %\%\..\11".
c a VC4XCc$v >9t s& 1\ "�` t
Telephone Number: NI'Nb- CJa1-t\c?t
NOTIFICATIONS SHALL BE COMPLETED IN THEIR ENTIRETY, DATED AND SIGNED -
INCOMPLETE NOTIFICATIONS WILL NOT BE ACCEPTED AND WILL BE RETURNED BY D.L.I.