185 Notification of Deleading 1992 a
a
DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR 6 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 5197
pp FILE NUMBER
Lead Paint InspectorSHAQO(.( S'1 \ t5EAT p`1� Date of Inspection 5 - 1 - Iz
Contractor performing. project D$E2� 't-1, AN9 LSot4
Address of Project _
C
Building Name (if any) Fi`�� L ... - Floor
Street Address IFS rJ '/li . PA 2ih 5 C , - Apt. No.
city u2? ' � rP l \1 V . zip nro 60
Licensee 33 3
Deleading Method: - DRY SCRAPING) BEAT GUN CAPSL_ T.A DE.MCLITION
(circle all that apply)
POWER SANDING ci:AGSTIC
If "Other' selected, please explain
CT=
Check one: dwelling is Multi-family
Start date t P.'1 Z. 6
When will work be done: =am )C pm -
•
"'-Project Supervisor Name
single family
Completion Date
Property Ownez flp L( N -1 1 b$ Dom '
Address
X
X V N
weekends? - P G 55
i'.\-e4 t.{ :J”\-License 9 : 33
3 %c P/N . h.4 -- A-13-nti
City State
Telephone
H 5 - 53 'i - 3'1 q
In case of emergency, contact what person:
Phone: Area code required day
00348/5
Zip
F.-.0 Su1 ;t. .
■ - ICA -
3 7- D
(OVER)
evening
Li I -242 - 3z3o
rev 11/16/89
a
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In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
--C. 111 5197, 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 pf deleading. -- -- - .
1. Occupants of-.the dwelling unit
_ - 2. - A21 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 read
and understood the Commonwealth of Massachusetts Deleading Regulations;- 454 CMR
-22.00, and 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 his/her knowledge and belief.
_..__Date _ \ G
`1 , [G Z Signed• -�,..�„1
Title--`5 c1
• COmpany:" 1 7 5- . : .'v
-{% 1:-r%4C : r Cm
0034B/6
rev 11/16/89