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38 Notification of Deleading 1994 In accordance with Chapter 717 of the Act] of 1987, Massachusetts Cer.crai Caws C. 111 5197, 454 OMB 22.00 and 105 CMR 460.000, notice of the date and method(s) of removal or covering of paint, plaster soil or other accessible material containing dangerous levels of lead, is to be provided to the following persona at least five days prior to the beginning of deleading. 1. , Occupants of the dwelling unit 2. All other occupants of the residential premises, if any 3. Director, Childhood Lead Poisoning Prevention-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 coed and understood the Commonwealth of Massachusetts Deleading Regulations, 454 C.MR 22.00, and Lead.poisoning Prevention and Control Regulations, 105 R 460.00, and that the information contained in this notification is trce and correct to the best of his/her knowledge and belief. Date ////o /91 Signed: Title: ( j4-eiL76i Companyf.Ja4-2 j- 72ro7.y4,4V 7,e/7/7: ("izOd //.,�/ Address rd/S�a/ri erJ/��/,2%,-O..U. , a,.../ i!/Jl�)4nii/?O/ Telephoneu Office Use Only THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF INDUSTRIAL SAFETY Too CAMBRIDGE SIRECT,AM. T/OT LVi TON,MASSACHUSETTS 02202 0034u/6 rev 11/16/89 DEPARTMENT 0000GOLIC HEASTH/DSPARTMSNT or LAD;,^ NOTIFICATION OF DCLEADING WORK All sections of this form must be completed in order to comply the notification requirements of M.G.L. C. 111 5197 Pn(firr- NOV 1 1994 th /y d1 / FILE NUMBER Lead paint Inspector Ie tZ e �, 4IL{Pv A Date of Inspection Contractor performing projech,] 4,, ,z hcv/v„ec License • Address of Project '�77 / Building Name (if any) 3 /,�p�i„o Q ST Street Address , d$ Ran-re # St City 129. otryniC Zip /92'4 Deleading Method: DRY SCRAPING (circle all that apply) POWER SANDING If 'Other' selected, please explain Floor Apt. No. O /Otoo /// 2/9/ DOo 76,5 Check one: dwelling is Multi-featly Start date /7// 7/117 When will work be done: am R single family Completion Date /1/ 0 /fu St weekends? 1 Y45 Project Supervisor Name Tir, F 6utin�cl License 1 000'74? Property Owner ,/Qn/p,/ C/Kin s / Ro Address City Telephone 7-20.140 m/{o.7 ri/ S1 ys/a State In74 Zip O/04o In case of emergency, contact what person, /-- Phone: Area code required day 3 5A 7 £0S.k evening ti/3 Sad ROtia. (OVER) 00348/5 rev 11/16/89