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65 Notification of Deleading 1993 I JAN141992 DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR & INDUSTRIES NOTIFICATION OF DELEADING WORK All sections of this form must be completed in order to comply with the notification requirements of M.G.L. C. 111 ss 197 FILE NUMBER Contractor performing project: Brian S. Walker Certification# DC000940 Lead Paint Inspector_Alfredo Ferrari Date of Inspection_10/19/92_ Address of Project Building Name (if any) Floor 1st & 2nd Street Address 65 Franklin Street Apt. No. City_Northampton, Zip _01608 Deleading Method: DRY SCRAPING HEAT GUN ENCAPSULATION DEMOLITION (circle all that apply) POWER SANDING CAUSTICS REPLACEMENT OTHER If "Other" selected, please explain Check one: dwelling is Multi-family Single family_X Start date_1/18/93 Completion date 2/28/93 When will work be done: am_8:00 pm _8:00 weekends? Yes Project Supervisor Name Brian S. Walker Certificate # DC000940 Property Owner _Nancy Re Address 8120 Old Oak Drive City_Springfield, State VA Zip_22152 Telephone_(703) 569 - 9686 In case of Emergency contact: Brian S. Walker Phone: day (413) 256 - 0351 evening same 6034B/5 REV 1/6/89 a In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws C. 111 ss 197, 454 CMR 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 persons 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 Dept 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 S° 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 he has read and understood the Comm. of Mass. Deleading Regulations, 454 CMR 22 .00, and the Lead Poisoning Prevention and Control Regulations, 105 CMR 460. 00, and that the information contained in this notification is true and correct to the best of bis knowledge and belief. Date 1/12/93 Signed/ 00346/6 74,1 Tit le_Sole proprietor d/b/a Company _WALKERWORKS Office Use Only