HomeMy WebLinkAboutEddy St. #50 - 7/31/1996E.COMM01;11UALTHI OF ,MASSACHUSETTS.'
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(f� Department of Labor & Industries and Department of Public Sealth
NOTIFICATION OF DELEADING WORK IIr III
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' All soati�ons ` of'thie form must ba complotad in, ordor' to`comply
,I„,., ,,,.;,vi,th. tha..notifdaption; roquiremonts. of MGg7,. Iq-111,. ,5;.19.r•••
.45.41 CMR'22.0 a+;1� 10$, CMR 46o. o0o, as, mast ;econt,lyl amo,>ic)od ,
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FILE NUMBER: (AGENCY USE)
Contractonperforrning:project Lead Source/Dennis Ranson;., Ufense #•DC00091 2
Exp.,date 9/14/96
Lead;Paint Inspector Environmental Lead Detection License•N
Oil ]-I'm 1 Date of Ins Iq.9p1 on
I :,. Llb,l J . H{I1 1 ,IY .1. - I ILI J•.. p.... g,Y. �O , ,
If,1lgwl riskIldelcadingJwork'is•'being performed,' complete tha following line:
Property, -,owner Mansfield Housing Auth.Agent (s) Fr,ancene Bragga
"Addressof' Pro ect:
r,: ) N Mur> field Housing Auth. Cloor
Bui ding Nagle (lf anj
10 VfioJ hnl rin 1 !� IL . -
Stree`Jcidress' SD "eddy Street' Ape INo
L 11.4f1
city.•;•:.....;,. ManSi,Q] d,,..,MA z:lp.:.6204g.
, I I •. ,'1 Ca
Dq]eading. Method .. Wef/Dry Scraping Heat, Gun alystics
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Llquld'Enoa'psulantl overing Demolltron Replacement' Other
If.:•"OYher!':'selecte�l, ]ease .explain N/A ,.
.. .. ..... II?. ...
Check 0ne:e,1;,I •:.dwelling., is, • ulti-family singlo, Family XX
Start idate" ..' 7/31 /96 Completion date' 71/31 /P96
When• will.,worJ.,!b:§ dojlo i,'A,M 1cx. P.M.. Weekendst?. NO,
Project. SupervisorIIs name Christopher Roy License I! D5002126
Property, Owner Mansfield Housing Authority,
Address 22 Bicentennial Court
City, Mansfield '.'': State MA Zip 02048
Telephone 508-339-6'890
In case, of•emergency, contact Scott Knightly
Phone: day 603-749-9279': evening 603-808-2396
(over)
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In accordance with Massachusetts, General Laws c. III 5 197 CMR.22.00, and'105 CMW,460 000, notice
of the date and methods(s);iolf;,romgval'or covering of paint, plaster ,oi•, ,other accesslbl9'• materials
of the dat Band method.,
,l... ,f •load'is"Co'be' provided and must+'be:rocei•vod by the following
persons, at loastt•n`(10)'%day prior to beginning of doloading.
t. i:fivaii A.''1'{L
1. Occupants of the dwo),ling„unit
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2. All other occupants,.,of.,,therosidontial promises, if any'
3. Director, Childhood LoShcng'"Poisoning Ptovonl'lon Program '`! Fax (617) 753-0436
Department'ofPublic:Noalth; ,470 Atlantic Avenue, Boston, MA 02110
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4. Director, Asbestos a Lead Program Fax (617) 727-7560
Department of Labor'4 InUusC ties.
..�_. Room, 11006;In10.Q'cCa ridge. Street;
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.'Boston, � MA> 02202,`:-°' � ..........
5:"'Local'IBoard of Health/Code Enforcement Agency
6. -Massachusetts NistoricaL CAmmission (If promises Is -listed on the' State Register
Ion
220;Morrisjoy,•Slvdi..I(
r,,}1.,-:-!a+I madeiuponirecoipCplacaSoftan50rderhift aCorxectst be
Boston, MA OZ125 Violations or at least: 30!,days' prior to
initiating prevenrJlvgndeiaaoing)
Fax'(617) 721-5120
D•leading•Contractor...............
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The ,updersigned..hereby states, under the pains and penalties":of"perjury,-that
he' - .'has'';read"ando,understood the Commonwealth of Massgchusetts Deleading ,
Regulations, 45Q;CMR 22i;0,0;":a�id'Leadinq Poisoning Prevention and Control
;'Regulationst105�CMff1.60:000,".and that the information; contained.,in,,this
notification is a rtie'arid:'c'oriect to, the best of his/her-7knowledge and belief.
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Date 6/25796 Si gned:�-1 OK�f
..'title: President
Company: Lead Source;.:, .t,.'..,.,
$roperty'oxn•r '(If"owner';o'r''unllconsed ownor's agent will be performinq^low-risk doloading work)
I. certify that L 1�aveFcom�lted with the training requirements"of the
Commonwealth of Massachusetts Lead Poising Prevention ;and Control Regulations,
105 CMRt460 175,P';forrwowner��agent";low-risk abatement and contairunent. ,I
further cert>Ey.Ehat•+171.or myIagent`will be performing
the following ;,18 ; lsk activities,; (I have circled all (that apply).
applyi n,g. liqu Id.encapsul'ant • capping:basoboards
applying extarior;yinyl,siding covering surfaces
..-.—,-....--•somoviny.,dooc�:•.:cabi,na (',.. doors, shuttors .. .
I'cortI(y`tha t'al 17 the; in form,tlon contained In this notification Is 'trueand corroct to the
best of my' knowlodgoiand',�bollaf,
Date: 6/25/96 "(%; ' ii:: signed: _
REV 10/12/95
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