HomeMy WebLinkAboutEddy St. #55 - 7/18/1996;.',',.=Q ONWEALTH OF •MASSACHUSETTS.'
Department. of Labor &_Industries and Department. of Public Health
NOTIFICATION OF DELEADING; WORK ,i i 1,
Ali aaati'ona of'thie form mvaC he oomplotod in* osdur'to'aoaiply
with: the,notifi.aaCion;,cugvitowonts
\1�4`7� I 45A Q•IIi �22 00 agd1 10$ Q'IIL ,4GO.000, ap moat ;aaant�ly,•1`,mopr�ad ..
•• FILE NUN=: (AGENCY USE)
Conttactogpedorming:project Lead Source/Dennis Ranson; -,.License #•DC000912
Exp.,date 9/14/96
Lead; paint Inspector Environmental Lead Detection License•#
L1.,1 r,l l:lx, Date of Inspection,
If, tow-risjc!deleadinglwork i.s•'being performed,' complete,tho following line:
Propertyowner Mansfield Housing Auth.Agent(s) Fr,ancene Bragga
'Address o£ Project_ ,
Buil'din�Nae�(1'ENany)` (4�nsfie,ld Housing Auth. Floor,
Stre'e"rddresslr 55 Ede Street ` Apt
L p1ee
City,;......>;•.Mansi,t ;.,�lA zap. 02048,.,
in
Dgea lding Method Wek/Dry Scraping Heat•Gun �aystics
J1: 1 bl D I l 1 I - (• tl
LiquidlEnca'psulant`. " overing Demolition Replacement' Other''•
If "Oth, !,:•selectea,Iplease explain
1, I;,... ,
Check One: n ,:j • .dw011•t n9, is,multi-family singlo, family XX
Start date'7/15/96 Completion date T/18/96
cVhen•wi11.;Iwgrklbe;;dope A,M 1Cx. P.M. (Weekends,?'. No.'
P,lpnil
projectSupervisor,. s name Christopher Roy License O DS002126
Property Owner Mansfield Housing Authority,
Address 22 Bicentennial Court
City. Mansfield State MA•, zip 02048
,Telephone 508-33.9-6'890
In case, of •emergency,:;contact Scott Knightly
I
I
Phone: day 603-749-9274•. evening 603-868-2396
(over)
i
In accordance with Massachusetts, General. Laws c. 111 5 197 CMR. 22. 00 and 105'CMRiA60 OOO+notice
of,the date and methods(s))iof:-,removal' or. covering of paint, plaster, 9.p other' accessible°materials
containing 'dangerous'1`evelsoof"lead''ls'10 be provided and must:be:recebved by the following
persons, atleastt•n`(10) "days prior to beginning of doleading.
ill 1,..rCl , TL,o:.".t'Io L, ,..,.. ..
1. Occupants of the dwo;ligg unit..,
2. All other occupants,:,of,�tho,,rosidontlal promises, if any',. .'.t. •i ,�t,
3. Director, Chlldhood''Logding"Poisoning Provontion Program " "r,•' 'Fax (617) 753-0436
Departmentof Public,' Heal th; 470 Atlantic Avonuo, Boston, NJ1 02110
4. Director, Asbestos & Lead Program Fax (617) 727-7560
Department of Labor'4 Industries.
••_,_, Room, 11006;11'10,Q4,Ca p idge. Street; •; �;;(tyf;� f1Ypp -
BOSCon,'MA 02202,, "�-"'.""........ ... .
5. "Local"lBoard of Health/Code Enforcement Agency
6. Massachusetts Historical Ciommission (If promises is listed on the state Register
"220;Morrlsstoy?BI,vdl;,l), 1'o, !;;n of Hlstoric Placosy thisnotificationmust be
"•'Boston;-: MA'.Og125.`=":' made upon recoipt:;of. an-Order::to Correct
violations or at, least: 30!dayys prior to
initiating prevent)iyendeloading)
Fax (617) 727-5120
. •.. ir. q'iJ..
DaleadEn9'•ConCraator••._..... _.,.>....:..... . _................. . . .
The ,ulidersigned;;hereby,states, under the pains and penalties"�of"perjury, that
he(sh... read•'andeunderstood the Commonwealth of Masgachusetts Deleading,
Regulations,,,,,454;�'CMR1;22:;00' and'Leading Poisoning Prevention and Control
Requlati:onstw105CMR}�,4„60i OOO; and. that the information;, contained•,in, this
noot fication is<:tr ue'and;d'or'rect`to•the best of his
knowledge and. belief.
ci t .;' O
Date 6/25796
President ..
Company; Lead Source;.:, .,..',,•.,'
'Property'owner"'(I f''ownar;;;o'r'•Unl iconsed owner's agent will be porforming^low-rlsk doleading work)
I certify;athit I ,havve, complied with the training req'uiremerits'of .the
commonwealth of'6Massaehusetts'Lead Poising Prevention 'and Control Regulations,
105`CMRp460:175;;,..forflowney/agenti low -risk abatement and containment. ,I
further ;certify thatlI,or my agent will be performing •----
the followl.ng lov rl.sk activztles.;(I have circled all„that apply):
applying liquid.encapsul'ant 'capping:baseboards
applying oxtorior,`vinyl.Isiding covering surfaces
-•-'-•-•--comoving.;doors;,.;cabinot,.. doors, shuttors .,_„•.•,,,,•..,., "
I cortify that "all•thm infofma,tlon concalnud In this notification is true And corCact to the
best of my' k!wwIgcjgo,;and'r�@oliof.
r• ,
Date: 6/25/96 ^:!i 5' (6:':''v signed: _