15 Notification of Deleading 1995 ..34 =440,
DEPAP:M:year PUBLIC IIaA'.TII/DCPAHTM!LT OF !Ara\
NOTIFICATION OF DCLEADING WOW(
All sections of this form must be completed in order to
the notification requirements of M.C.L. C. 111
FILE NUMBER
Lead Paint Inspector
Contractor performing projec
Address of Project
Building Name (if eny)
p_i..sEOWE
EA elf - 419qs
Co �Iv den
9Ji*YY/AN WARD OF HEALTH
/ /2/?(i % ` Date of Inspection
Street Address /1)
City / crew,!
iligoGQ .y .
A74
Zip
r /c /c
License t Ct C 76
Floor
Apt. No. At/S
Deleading Method: DRY SCRAPING ',ISM' GUN ENCAPSULATION 1 DEMOLI 0Y
;circle all that appl'y) '
POWER SANDING
If 'other• selected, please explain
CAUSTICS RC ^p;,;,C •�?NT/
OTHER
Check one: dwelling is Multi-f:.:nily single family j'
Start date d/3/9 1 Completion Date '37/g/95--
Whoa will work be done: am /5 pm weekends? %e
Project Supervisor Name Illhn 4-- ,'a, /. tL/ License 100074,6
Property Owner S/ P ATE" rt 01-1
,
Address 8 ‘1 ), MILO CIK
City J-wP,-, ie State /}24 tip (D/O60
Telephone
y/ ,5 2 U n 9/-;‘
//G�
r ��{,n - (,o(ak
In case of emergency contact what persons -
J
Phone: Area code required dayy/ g-cj o17-?QS&. eveningj//3
(own)
0034D/5 rev 11/16/89
In accordance wit
C. 111 5197, 454
removal or coved
dangerous levels
days prior to the
h Chapter 777 of the Acts of 1987, ,Massachusetts General Laws
CMR 22.00 and 105 CMR 460.000, notice of the date and method(s) of
ng of paint, plaster soil or other accessible material containing
of lead, is to be provided to the following persons at least five
beginning of deleading.
1. . Occupants of the/dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisoning Preventio •Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical Services
Department of Labor and Industries, Division of Industrial Safety
100 Cambridge Street, Room 1101, Boston, MA 02202
5. Local Board of Health/Code Enforcement Agency
6. Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that s/he has reed
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead-.Poisoning Prevention and Control Regulations, 105 CMR 440.00, and
that the information contained in this notification is true and correct to the best
of his/her knowledge and belief.
Date .S////QT
Office Use Only
00345/6
Signed,
Title*
Company*
Address
Sea • • z i w
Telephone(' ,/„3_
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF L4RORAND INDUSTRIES
OIwSION OF INDUSTRIAL SAFETY
700 CAMRR/DGESWRFE7,RM. f rOf
tug ION,MASSACHUSETTS O2202
( S
rev 11/16/89