HomeMy WebLinkAboutEddy St. #57 - 8/12/1996;.',';;.CgMMONWEALTH OF ,MASSACHUSETTS.'
S Department.of Labor & Industries and Department of Public Health
:..ra •:..�... „ ; . , ..: .:.;;: •,NOTIFICATION , OF DELEADING,
::!:.:::: : ., ... :.:.,....
•• •'`l11`aeationa: or.. this must be aomploted Yn'ordar'to•ao 1
pa ::. i• •.l{:'.,:;ixi.th7 tho.:noti!J•,option:xoquiramonts:. of:M. G:j,.;la.,lllr,5,1d97,r' �
,46A)CMR'�2:OO.ar,1�105.49i,460.000,a¢, moat.;ecan,t,ly,,w:n'1ud, ..
1 FILE NUMBER: .. (AGENCY USE)
i '
A,.: L•.:.:
Contractor,performing;prpject' Lead Source/Dennis Ranson;., Vicenso #•DC00091 2
4.
Exp.date 9/14/96
Lead:Paint inspector Environmental Lead Detection License-#
Date of ti Inspecon,
If, low riskttdeleadingtfwork.4is'being performed,complete the following line:
Property'•,oWner Mansfield Housing Auth. Agent(s) Fr,ancene Bragga
Address of Project',,, _
r -,A C .rnr 0.l r , ' LN4'
fn sfie,ld Housing Auth.
PlooildlnaNae (anyBur'
.. 1 U'tilrAJ ill}!A rr L: f .,
Ei�.dY Street'
Stree J `ddress1 57 p
L � �{
City, Mdtlsi�ld,...,MA' Zip
,:.: - ..
DQleading.Method Wef/Dry Scraping HeaL.Gun Caystics
eo A rr ,
Liquid' Enaa'p'sulant ' , ,Ar overing Demohtron Replacement Other
Ifs'Other!!;seleR, ed,.a1 ,lplee,explajn N/A .
Check One:n,,:;,j ;dwe111nq:is,.mul,ti-family singlo•family XX
, r..
Start date I!,8/12/96 Completion date 8/12/96
,.When will ,worbe;;dope•,1. A.M fix. P.M. Weekends?. No
Project,Supervisor Is, nameChri.stopher Roy' License ODS002126
Property Owner Mansfield Housing Authority.
Address 22 Bicentennial Court
city. Mansfield State MA „
Telephone 508-339-6890
In case.of •emergency,:.contacL'
Phone: day 603-74979274:
Scott Knightly
evening
(over)
Zip 02048
603-868-2396
In accordance with Massachusetts, General Laws c. ill 5 197 CMR.22.00 and 105,04RA 60.000-notice
of the date and mothods,(s),'OS;•:removal or covering of paint, plaster,9,F, other accessible materials
°v
containing dangerous °lovejso C''load'is to he' provided and must,- be.receivod by the following
persons, at least -t•n (ior to beginning of doloading.
1. Occupants of the dwol.ling,unit
2. All ocher occupants,:,ofrtho,, rosidontial promises, if any'.
�.
J. Director, Childhood Loading"Poisoning Prevention Program Fax (617) 751-0436
Department of Publlc:i(oalth,,470 Atlantic AVenee, Boston, MA 02110
4. Director, Asbestos & Lead Program Fax (617) 727-7560
Department of Labor'& Industries.
-•,__, Room,_ 11006,t'elog.Ca ,ridge Street; -;y }y�Ut:'; qui•a:•'
'Doston;�MA 02202i� - -
5: 'LOCal'4➢oard of Heilth/Code Enforcement Agency
• • 6. _ Massachusetts HSstoricai� Coiomission
220: Morriss
➢oston',.:MA;
Daleading-ContTactoT•••.... _...:._.:.....
(If promises is -listed on the State Register
of Rlstoric Places this notification' must be
made upon receipt ;of an -Order to Correct
Violations or*at.Least.JO'days"prior to
Initiating preven,Cflvp;ldeleading) :
.Fax (617) 727-5120
..................
.The .unders,igned,;,hereby,states, under the pains and penaltie's-.0f"perjury, that
he[she'has-read''and6understood the Commonwealth of Massgchusetts Deleading
Re.gulat.lons, 454 ;CMRP22 OQ.'and'lioadind Poisoning Prevention and Control
RegulatJonst 105'iCMR460'000,=and that the information; contained.,in,this
notsficationis".true':and,;'coriect`to•the best of his/her-7knowle84e and belief.
Date 6/79b Slgnod:
Title; President
company: Lead
'Pidpeity'Ownor '(If-ownor'b'r''unllconsed owner's agent will be parforming^low-risk deleadiny work)
I certify7:that I liaveA;complied•with the training requirements"'of ,the
Commonwealth of Massachusetts Lead Poising Prevention and Control Regulations,
105 :CMR„960 175,iforrtowner/agentjow-risk abatement and containment. I
F.further,certify: that�I"or my ,argent will be parforming
the following low risk activities.,(I have circled all tha,L- apply):
applying liquid.encapsul'ant capping: baseboards
applying oxtorlor vinyllsiding covering surfaces
•------.removing•.doocs...cabl,ne t,,. doo rs, shut to rs ., ,.
I`cortl(y`that all':thoiinformation contalnod in this notification is true and Cryr Coct to the
best of myknowledge iandl,� Uoliof:
Dates 6/25/96 ^(li'.i' f,;;".•'t signed': _