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