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The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
S
r` Bureau of Environmental Health
250 Washington Street, Boston, MA 02108-4619
Phone: 617-624-5757 Fax: 617-624-5777 MARYLOU SUDDERS
Governor CHARGES BAKER TTY: 617-624-5286 Secretary
KARYN E.POLITO MONICA BHAREL,MD,MPH
Lieutenant Governor Commissioner
Tel:617-624-6000
p , DATE: `7 I� f www•mass.gov/dph
ND AAove,r, MA 0I145
Dear VICO-VEA, nL-J14.V-r—
I did a lead determination at the home or apartment you own at
i 0 DOW 5. -f�- I :50ECem
This determination found lead in violation of the State Sanitary Code, 105 Code of
Massachusetts Regulations (CMR) 410.750(J). This violation also constitutes a violation of the
Lead Law, Massachusetts General Laws (MGL), chapter 111, section 197, and the Regulations
for Lead Poisoning Prevention and Control, 105 CMR 460.000, set forth by the Massachusetts
Department of Public Health. The law requires owners of homes or apartments built before 1978
to have lead violations deleaded for full compliance or brought under interim control when a
child under six years old lives there. A private risk assessor must do a risk assessment and give
you a lead inspection/risk assessment report before you can proceed with interim control. A
private lead inspector must do a comprehensive initial lead inspection and give you a lead
inspection report before you can proceed with deleading for full compliance. If you already
have a Letter of Compliance for this property, please complete the last page of the Order to
Correct and send it to me within 14 days.
The Order to Correct that comes with this letter has important information telling you:
• what you need to do
• what deadlines to meet
• what documents you must send to this agency
• who can do the necessary deleading work
• what the penalties are for not meeting the requirements in the Order to Correct
• what your options are if the property has been previously deleaded
Please call me (insert inspector name/number) as soon as possible to discuss this Order to
Correct and how to meet the requirements. The following information explains the deleading
process, if the property has not been deleaded previously.
Revised 3/2016 1
Hiring a Lead Inspector
To help you take the first step—getting a full inspection or risk assessment—a list of licensed
private lead inspectors is enclosed. We recommend that you check references and make sure that
the lead inspector is still licensed before hiring him or her. You can check on the license by
calling the Massachusetts Department of Public Health's Childhood Lead Poisoning Prevention
Program(CLPPP) at 1-800-532-9571. CLPPP can also provide you with a list of licensed private
risk assessors for interim control and other helpful materials, including brochures explaining the
difference between deleading for full compliance and interim control. Again, you can get these
by calling CLPPP at 1-800-532-9571 or by checking our website at www.state.ma.us/dph/clppp.
Requirements for Doing Deleading Work
High-risk deleading: If you need to or choose to have high-risk deleading work done, such as
having lead paint stripped or scraped, you must hire a licensed Deleading Contractor. A list of
licensed Deleading Contractors is enclosed. Just as in the case of inspectors, we recommend that
you check references and make sure the Deleading Contractor is still licensed before signing a
contract. You can check license information by calling the Department of Labor Standards
(DLS) at 617-626-6975.
Moderate-risk deleading: Before you or your agent can do moderate-risk deleading work, such as
removing windows and woodwork, you must take a course,pass a test, and get an authorization
number from the Massachusetts Childhood Lead Poisoning Prevention Program (CLPPP). These
courses are given by a number of groups and organizations at various places, times and prices.
For a list of approved moderate-risk deleading training providers, call CLPPP at 1-800-532-9571
or visit our website at www.state.ma.us/dph/clppp. Remember that you still have to meet the
deadlines listed in the Order to Correct. If a course for owners and their agents to do moderate-
risk deleading is not available at a convenient time or place for you to meet the deadlines of this
Order to Correct, you won't be able to do moderate-risk deleading work yourself. In that case,
you will then have to use other methods to delead, or hire a licensed Deleading Contractor. The
licensed Deleading Contractor license number will begin with a"DC." Depending upon the
kinds of hazards found and how you want to address them, you may also be able to hire a
professional to do moderate-risk deleading. This person, called a Lead-Safe Renovator,must
have completed the 8 hour Lead-Safe Renovator training plus an additional 4 hour training on
moderate-risk deleading. His or her authorization number will begin with an"MR." To get a
list of these licensed professionals, or to check their license information, call DLS at 617-626-
6975.
Low-risk deleading: Before you or your agent can do low-risk deleading work, such as covering
surfaces, you must read the CLPPP low-risk deleading work booklet. After reading the booklet, you
will take a self-corrected exam and mail it in to CLPPP. Once CLPPP receives the exam and
reviews it, you will be assigned a low-risk deleading authorization number. If encapsulation is a
suitable deleading method for your property, you must read CLPPP's encapsulation booklet. After
reading the booklet, you will take a self-corrected exam and send it in to CLPPP. Once CLPPP
receives the exam and reviews it, you will be assigned an authorization number. To get a free copy
of the low-risk deleading booklet, or the encapsulation training handbook, call CLPPP at 1-800-
Revised 3/2016 2
532-9571. A copy of the low-risk deleading work booklet can also be found on our website at
www,state.ma.us/dph/gIM under the "Delead on My Own"quick link.
Interim control work: If you or your agent will be doing other work for interim control, such as
structural repairs and cleaning of lead dust, you must take safety precautions and clean up in the
way described in the CLPPP booklet for interim control. To get a copy of this interim control
booklet, call CLPPP at 1-800-532-9571. Please be advised that some work can only be done by a
licensed Deleading Contractor, licensed moderate risk deleader (Lead-Safe Renovators who
have completed the 8 hour Lead-Safe Renovator training plus an additional 4 hour training on
moderate risk deleading whose license begins with an MR####), or low/moderate risk
authorized owner/agent.
Deleading work has to be done carefully to be safe. To protect the people who live in the home
or apartment,you have to keep them out of the home or apartment, or area being worked on, in
these ways:
• All people and pets have to be temporarily moved from the home or apartment for the whole
time that high- or moderate-risk deleading work is taking place inside the home or apartment.
You have to provide the residents with a reasonable alternative place to live for this period.
People and pets who have been temporarily moved from their home or apartment can only
come back after a licensed private lead inspector or licensed private risk assessor says it is
safe for them to return. The inspector or risk assessor does this after reinspecting the home,
including taking dust samples to assure that lead dust levels meet approved standards. This
reinspection will be done at least three hours after deleading work is all done.
• People and pets have to stay out of the work area while you or your agent complete most
low-risk deleading work, structural repairs, or cleaning of lead dust. They also have to stay
out of the work area while any deleading work is being done in common areas outside the
home or apartment. In this case, they must have another regular way (not a fire escape)to go
in and out of the building and they can use the area once the work is done and the work area
is cleaned up.
• People and pets have to stay out of the home or a artment for the workea while you or your
agent apply encapsulants with an airless sprayer. They also have to stay out for the day
during deleading in common areas when they do not have another regular way (not a fire o
escape) to go in and out of the building. When people and pets are out of their home or
apartment for the day, it means they can come back to the home or apartment after cleanup at
the end of the workday, and don't have to be out overnight.
All work for deleading and interim control has to be neatly and properly done, in a professional
way, and the home or apartment has to be returned to a condition that meets the requirements of
the State Sanitary Code, 105 CMR 410.000. Deleaded surfaces cannot be primed or repainted
until after they have passed reinspection by a licensed private lead inspector or risk
assessor.
You have to give written notice about common area lead paint violations to all other residents of
the building. The "Notice to Tenants of Lead Paint Hazards" is enclosed for that purpose.
Revised 3/2016 3
You also have to send a copy of the lead inspection report or lead inspection/risk assessment
report and any reinspection reports to all mortgagees and lienholders of record.
If your property has been previously deleaded, you may be eligible for a 30-day maintenance
period. Please fill out the last page of the Order to Correct and return it to me within 14 days to
take advantage of this option.
If you have questions about the Department of Public Health's Lead Poisoning Prevention and
Control Regulations, 105 CMR 460.000, you can ask me, or call CLPPP atl-800-532-9571. If
you have questions about the DLS Deleading and Lead-Safe Renovation Regulations, 454 CMR
22.00, you can ask me, or call DLS at 617-626-6975.
Remember to refer to the attached Order to Correct for more information about what you have to
do.
Sincerely, L
Inspector
Board of Health
Telephon $ u ` f ��
Revised 3/20]6 4
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ORDER TO CORRECT VIOLATIONS)
DATE: 11 f
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Owner or agent of the property located at
Be advised that an agent of the Board of Health has determined certain portions of this
residential property to be in violation of the State Sanitary Code, 105 Code of Massachusetts
Regulations (CMR) 410.750(J). This violation also constitutes a violation of the Lead Law,
Massachusetts General Laws (MGL), chapter 111, section 197, and the Regulations for Lead
Poisoning Prevention and Control, 105 CMR 460.000, set forth by the Massachusetts
Department of Public Health. The law requires owners of homes or apartments built before 1978
to have lead violations deleaded for full compliance or brought under interim control when a
child under six years old lives there. If you already have a Letter of Compliance for this
property, please complete the last page of this Order to Correct and send it to your code
enforcement lead inspector within 14 days.
Conditions exist in this residence which may endanger and/or materially impair the health of the
occupants of these premises.
DECLARATION OF EMERGENCY
The Director of the Massachusetts Childhood Lead Poisoning Prevention Program declares that
the presence of this violation of the Lead Law and the Regulations for Lead Poisoning
Prevention and Control constitutes an emergency pursuant to the Lead Law, MGL chapter 111,
section 198 and within the meaning of the State Sanitary Code,.105 CMR 400.200(B).
CORRECTION OF LEAD VIOLATION(S)
Revised 3/2016 1
The Lead Law, MGL, chapter 111, sections 189A-19913, and the Regulations for Lead Poisoning
Prevention and Control, 105 CMR 460.000, require the owner of a residential premises or
dwelling unit built before 1978 in which a child under the age of six lives have lead paint
violations either abated or contained (referred to as "deleading") for full compliance or brought
under interim control. The steps that you must follow are in the "Order" section.
The Lead Law,the Regulations for Lead Poisoning Prevention and Control, and the Department
of Labor Standards' (DLS) Deleading and Lead-Safe Renovation Regulations, 454 CMR 22.00,
require that residential deleading work be done by authorized people. The type of authorization
will determine the method of deleading that can be done. There are three levels of deleading:
High Risk Deleading
Only licensed Deleading Contractors or Deleading Supervisors, who will be on-site conducting
and/or overseeing deleading activities, can do high risk deleading activities. These activities
include scraping, stripping, demolition, and making large amounts of loose paint intact. If this
type of work is done on the interior of a unit,then the occupants must be temporarily relocated
until the work is complete and the unit has passed a reoccupancy reinspection.
Moderate Risk Deleading
Moderate risk authorized owners/agents and licensed moderate risk deleaders (Lead-Safe
Renovators who have completed the 8 hour Lead-Safe Renovator training plus an additional 4
hour training on moderate risk deleading whose license begins with an MR####) can do
moderate (and low risk) deleading. These activities include removal and replacement of building
components such as windows, and making a small amount of loose paint intact. If this type of
work is done on the interior of a unit, then the occupants must be temporarily relocated until the
work is complete and the unit has passed a reoccupancy reinspection. Owners interested in
becoming trained and authorized to do moderate risk deleading should contact CLPPP at 1-800-
532-9571 for more information.
Low Risk Deleading
Low risk authorized owners and agents can do some minor deleading activities such as covering
surfaces with approved coverings and encapsulating approved surfaces. Owners interested in
becoming trained and authorized to do low risk deleading should contact CLPPP at 1-800-532-
9571 for more information.
These rules on who is authorized to perform what kind of deleading work apply whether the
work is being done for full compliance or for interim control. An owner or owner's agent may
also make structural repairs, as defined in 105 CMR 460.020, and clean lead dust, as may be
required for interim control.
Revised 3/2016 2
ORDER
You are hereby ordered to remedy all violations of MGL, chapter 111, section 197 and 105 CMR
460.000, as identified by a licensed private lead inspector. If you wish to pursue interim control,
you must remedy all urgent lead hazards identified by a licensed private risk assessor. Whether
you pursue full compliance or interim control, you must correct the relevant violations in
accordance with the following schedule:
Within sixty (60) days of your receipt of this Order to Correct, you must provide
proof of the following:
1. A complete analysis of the property for lead hazards. Proof consists of one of the following:
• A comprehensive initial lead inspection report done by a licensed private lead inspector.
The inspector must inspect the interior of the unit and the common areas of the unit,
including the exterior.
• A comprehensive initial lead inspection and risk assessment report done by a licensed
private lead inspector who is also licensed as a risk assessor. This is only necessary if you
have decided to pursue the option of interim control. For more information on the interim
control program,please contact CLPPP at 1-800-532-9571.
• For previously deleaded properties, a post-compliance assessment determination(PCAD)
done by a code enforcement lead inspector. If you have a previously complied property
and fail to return the last page of this Order to Correct within 14 days, then you may no
longer be eligible for a maintenance period; however, you must still have the assessment
done. Only a code enforcement lead inspector can do this assessment.
2. An established deleading plan detailing who will be deleading and when the work will be
done. Proof consists of at least one of the following:
• A contract with a licensed Deleading Contractor, licensed moderate risk deleader (Lead-
Safe Renovators who have completed the 8 hour Lead-Safe Renovator training plus an
additional 4 hour training on moderate risk deleading whose license begins with an
MR####), or low/moderate risk authorized owner/agent. To check on the license for
Deleading Contractors and Lead-Safe Renovators who have completed the 8 hour Lead-
Safe Renovator training plus an additional 4 hour training on moderate risk deleading
whose license begins with an MR####, contact the Department of Labor Standards at
617-626-6975. To check on the authorization for low risk agents, such as vinyl siders or
carpet layers, contact CLPPP at 1-800-532-9571.
• If you or your agent will be doing the work, a copy of the authorization letter and a
completed"Documentation of Training to be an Authorized Owner/Agent And Intention
Revised 3/2016 3
to Comply with the Order to Correct" form verifying that all work will be done within
required timelines (see 90 day and 120 day requirements). This form is included in this
package.
Contracts with licensed/authorized people as well as an authorized owner or agent's
completed "Documentation of Training to be an Authorized Owner/Agent And
Intention to Comply with the Order to Correct"form must also specify that the unit will
meet acceptable lead dust levels under 105 CMR 460.170, as determined by the
licensed. lead inspector or risk assessor's dust wipe sampling. Should any of the dust
samples fail to meet acceptable standards; the last authorized person who performed
high- or moderate-risk work will be required to reclean the entire unit until all dust
samples meet acceptable levels. If a low or moderate risk authorized person did the
deleading and dust samples fail three times, a licensed Deleading Contractor will be
required to reclean the entire unit until all dust samples meet acceptable levels.
Within ninety (90) days of your receipt of this Order to Correct, the following
work must be completed and reinspected (including passing dust wipes if
required):
1. All high and moderate risk deleading on the interior of the unit must be complete,pass the
visual reinspection, and dust wipes.
Please note that if high or moderate risk activities are done on the interior, then
encapsulation cannot be done until after all of the high and moderate risk work has been
reinspected and dust wipes have passed.
2. Removal and replacement of doors, if chosen as the method of deleading, must be complete
and pass visual reinspection. ,
3. Loose surfaces in the interior of the unit must be made intact by the appropriately authorized
person, be covered, or otherwise deleaded and reinspected. This includes loose surfaces
being prepared for encapsulation(DO NOT encapsulate these surfaces until after a
successful reoccupancy reinspection). Making paint intact on the interior of a unit requires
dust wipes at the reinspection. There cannot be any loose paint in the unit by the ninetieth
day.
4. For those owners pursuing the interim control option, rules 1- 3 still apply; however, only
"urgent" lead hazards are required to be corrected. In addition, all required safeguards and
structural repairs relevant to the interior of the unit must be complete and have passed
reinspection and dust wipes, if required.
Proof of this work consists of a copy of a reinspection report from a licensed lead inspector or
risk assessor and copies of passing dust wipe results, if dust wipes were required. Copies of these
documents must be provided to this agency by the 90th day.
Revised 3/2016 4
Within one hundred and twenty (120) days of your receipt of this Order to
Correct, the following work must be completed and reinspected (including passing
dust wipes if required):
1. Any low risk activities on the interior of the unit that were not done by the 90th day deadline
must be complete. This includes encapsulation of interior surfaces that were previously made
intact.
2. All required deleading in the interior common areas and on the exterior must.be complete,
pass the visual reinspection, and dust wipes if they were not needed for a reoccupancy
reinspection.
3. For those owners pursuing the interim control option, all of the "urgent" lead hazards must be
corrected on the interior, common areas, and the exterior. Also, all required safeguards and
structural repairs relevant to the interior common areas and the exterior must be complete and
have passed reinspection. For interim control, a final set of dust wipes is required to be taken
at the final reinspection even if dust wipes were taken previously for a reoccupancy
reinspection. This means that two sets of passing dust wipes are needed for interim control
when a recoccupancy reinspection is completed; one set for the reoccupancy reinspection and
one set for the final reinspection.
Proof of this work consists of a copy of a reinspection report from a licensed lead inspector or
risk assessor, copies of passing dust wipe results, and a copy of a compliance document. Copies
of these documents must be provided to this agency by the 120th day.
PROSECUTION AND CIVIL PUNITIVE DAMAGES
Failure to comply with any of the deadlines set out above will require this agency to initiate
criminal or civil proceedings against you within seven(7)business days. Compliance with this
Order to Correct will be determined by this agency's receipt of the appropriate documents within
the specified deadlines. Documents should be sent to your code enforcement lead inspector
(provide inspector name and business address).
Inspection documents required by the 60th day deadline. One of the following:
❑ Comprehensive Initial Lead Inspection report by a licensed private lead inspector;
❑ Comprehensive Initial Lead Inspection report and Risk.Assessment report by a licensed
private risk assessor if pursuing interim control;
❑ Post-Compliance Assessment Determination(PCAD) done by a code enforcement lead
inspector.
Documents required by the 60th day deadline. At least one of the following, although there
may be a combination of documents:
Revised 3/2016 5
❑ A contract with a licensed Deleading Contractor, licensed moderate risk deleader, (Lead-
Safe Renovators who have completed the 8 hour Lead-Safe Renovator training plus an
additional 4 hour training on moderate risk deleading whose license begins with an
MR####), or low/moderate risk authorized owner/agent;
❑ A copy of an owner/agent authorization letter from CLPPP and a completed
"Documentation of Training to be an Authorized Owner/Agent And Intention to Comply
with the Order to Correct" form;
❑ If you or your agent will only be doing structural repairs and lead dust cleaning for
interim control, a signed written statement attesting that this work will be completed in
accordance with the required timelines.
Documents required by the 90th day deadline:
❑ A Letter of Lead Paint (Re)occupancy (Re)inspection Certification issued by a licensed
lead inspector or risk assessor, in cases where high- or moderate-risk deleading work
occurred,requiring occupants to be relocated from the unit for the duration of the work;
❑ Copies of results of all dust samples taken by the licensed lead inspector or risk assessor,
and copies of all reinspection report(s) issued by a licensed lead inspector or risk
assessor;
❑ Copies of any invoices documenting that all work to-date was conducted by appropriately
authorized people, including a signed invoice for structural repair work and cleanup of
lead dust.
Documents required by the 120th day deadline:
❑ Copies of any invoices documenting that all work was conducted by appropriately
authorized people, including a signed invoice for structural repair work and cleanup of
lead dust;
AND one of the following:
❑ A Letter of Full Deleading Compliance issued by a licensed private lead inspector;
❑ A Letter of Interim Control issued by a licensed private risk assessor;
❑ For previously deleaded'properties, a Certification of Restored Compliance(an addendum to
the original Letter of Compliance)issued by a code enforcement lead inspector.
In all cases, the owner must ensure that a copy of the deleading notification is sent to this
agency at least ten (10) days before the start of any deleading,no matter who is performing
the work, and whether it is for full compliance or interim control.
Revised 3/2016 6
The law provides penalties of up to $500 for each day of noncompliance. In addition,you
may become liable for civil punitive damages equal to three times any actual damages for
failure to comply with this Order to Correct if a child becomes poisoned.
CORRECTION OF VIOLATION BY CODE ENFORCEMENT AGENCY
If within the time periods stipulated above this residential property is not brought into full
compliance or interim control, this agency may contract with an authorized person or authorized
persons to correct the violation(s) and obtain a Letter of Full Deleading Compliance or a Letter
of Interim Control, and bill the owner, or initiate court action to reimburse itself.
RIGHT TO A HEARING
You may request a hearing pursuant to 105 CMR 460.900 of the Regulations for Lead Poisoning
Prevention and Control, in conjunction with the procedures of 105 CMR 400.200(B),the
Sanitary Code provision for hearings in emergency public health matters. As already noted,the
aforementioned violation constitutes an emergency. (See "Declaration of Emergency" section.)
As such, you may request a hearing only if you have complied with this Order to Correct. The
hearing will be provided within ten days of your request. This agency shall issue a written
decision within seven days after the hearing.
FEDERAL REGULATIONS
Some federal financial assistance programs require additional environmental investigation. If
you are planning on or have applied for a federal loan program, please contact discuss these
additional requirements with the program administering the loan or grant.
Inspector Director
Board of Health
Telephon�cf7
Revised 3/2016 7
If your property already has a Letter of Compliance, you must fill out this form and return it to
your code enforcement lead inspector within 14 days. Please include copies of ALL your lead-
related paperwork for this address.
Your code enforcement lead inspector will review the paperwork for this address and contact
you to schedule a post-compliance assessment determination (PCAD). Upon this review and a
site visit,you may be eligible for a 30-day maintenance period, during which you may be able
to fix the hazards yourself and your Letter of Compliance remains valid.
Failure to return this form to your code enforcement lead inspector within 14 days may
disqualify you from this option, requiring you to follow all of the rules and timelines outlined in
this Order to Correct. Only a code enforcement lead inspector can do the required inspection
work for previously complied properties. The inspection and reinspection services are provided
for free. Please complete and return this form immediately in order to take full advantage of
this 30-day maintenance period.
Please print clearly:
NAME: DATE:
ADDRESS:
ZIP CODE:
TELEPHONE NUMBER: ( i
ADDRESS OF THE PROPERTY CITED:
ZIP CODE:
OCCUPANT(S)NAME:
OCCUPANT'S TELEPHONE NUMBER: (_)
Please check off which documents you have attached to this form:
❑ Lead Inspection Report
❑ Risk Assessment Report
❑ Letter of Full Initial Inspection Compliance
❑ Letter of Abatement Compliance
❑ Letter of Full Deleading Compliance
❑ Letter of Interim Control
❑ Certificate of Maintained Compliance
❑ Certificate of Restored Compliance
Revised 3/2016 8
Other:
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Revised 312016 9
Executive Office of Health and Human Services
Jti Department of Public Health
J Bureau of Environmental Health
Ord - 250 Washington Street, Boston, MA 02108-4619
MARYLOU SUDDERS
CHARLES D. Secretary
BAKER MONICA SHAREL,MD,MPH
Governor Commissioner
KARYN E. Tel:617-624-6000
POLITO www.mass.gov/dph
Lieutenant
Governor
REQUEST FOR DETERMINATION OF LEAD HAZARDS
AND ENFORCEMENT OF THE LEAD LAW
Date: " bc 2010
I, f'U request the Childhood Lead Poisoning Prevention
print name of occupant
Program to inspect my residence or dwelling unit for lead paint:
The address of this residence or unit: 5 412k
Street and Apt/Unit Number
C? m , MA / The telephone
City or Town Zip Code
number to reach me there is: "' Z' Cry
Phone Number
The child(ren)under the age of six (6)years who reside(s) in this household is/are:
S.&O- la �-'Qf n6t&7, 0512,01Z217
Name Birth date Name Birth date
Name Birth date Name Birth date
Was the residence built before 1978? Yes No
I understand that the lead determination requested may include all rooms of the dwelling unit or
residential premises, common areas, porches and accessible exterior areas, as well as other buildings
within the property lines. I further understand that if there is a child under six (6) years of age in
residence, and the determination hereby requested identifies lead hazards in violation of Massachusetts
General Laws, chapter 111, section 197, and Regulations for Lead Poisoning Prevention and Control, 105
Code of Massachusetts Regulations 460.110 and .750, such violations must be either deleaded for full
compliance, or the unit must be brought under interim control, at the property owner's expense. The
property owner must correct all violations, whether for full compliance or interim control, within 120
days of the receipt of an Order to Correct Violations. The property owner must also submit within 60 days
of the receipt of such an Order, a copy of a signed contract with a licensed deleader, if one will be
necessary for the required work. If the owner or his/her agent is going to perform owner/agent deleading
work,the owner must also submit a special form within 60 days. If the owner fails to comply with the
Order to Correct Violations, the Health Department shall initiate judicial proceedings against the owner to
enforce the Order.
The Massachusetts Department of Public Health, Childhood Lead Poisoning Prevention Program
(CLPPP) conducts random audits of inspections conducted by private inspectors and risk assessments
conducted by private risk assessors following lead determinations. Such monitoring is performed to
assure the quality of services being provided to the public. By requesting this determination, you agree to
allow CLPPP access to your residential premises or dwelling unit after the initial determination and prior
to your returning once any deleading, whether for full compliance or interim control, is completed. Not all
private inspections or private risk assessments will be audited, so you may not hear from CLPPP
requesting access for these additional visits.
Please complete this form and email to Lorraine Simbliaris lorraine.simbliaris(d,state.ma.us, or fax
it to her at(617) 624-5778 or mail it to her at the address below. If you have not heard back from
CLPPP in 1-2 weeks, call Lorraine at(617) 719-1873, (617) 624-5741 or 1-(800) 532-9571.
Lorraine Simbliaris
DPH/CLPPP
250 Washington St 7' floor
Boston,MA 02108
SignAire of Occupant
CLPPP Form No.4,11-84 (BOHREQUEST.DOC)
Parental Req.for Determin.
Rev.6/99, 10/97,10/02,4/2011
>>UPLOAD LETTERHEAD IN THIS SPACE<<
LEAD DETERMINATION REPORT FORM
St.# S eet Name Street Type Unit
10 _ _._ ,u- 1 1 i
city Zip Code
H Few h C15
Date of Determination: 1 /9 /I
Sodium Sulfide expiration date: : /6 /1 Number of Rooms in Unit
X-Ray Fluores ppce: Mod-e-lIl,:,, S W #
Owners Name: IQI�I 1 V lC 2 �? _ f y� , � Property Type:
,
Owner Address: 31z1 ( Ck=' ❑�drulti
• le Family
,of-1'�t/iyt.doy-ef; hA f')19q Family #of Units
Contact Information: ❑Condominium #of Units
Home built before 1978? 7Y ❑ No ❑Day Care ❑Other
LEAD HAZARDS? es ❑No
Property Diagram/Unit Labels
Floor# (level within building of unit being inspected)
C b
BD ---------------------------------------------------------
--------------------------------------------------
AUOrl
----------------------------------------------------------
--------------------------- I----------------------------
A(Street Side)
A(Street Side) Start Here
A gray or black reaction to sodium sulfide or an X-ray fluorescence reading equal to or greater than 1.0 mg/cm2
indicates a dangerous level of lead and constitutes a positive determination and violation of the Lead Law.
Deleading must not be undertaken based on this report. A licensed lead inspector must do a full inspection
identifying all lead hazards in order for you to qualify for a Compliance Letter,
25 La Za 6A G GL r.1 S Oaf t ZZ7' /�>l/
Inspector's Name —�� License# Signattw Date
Inspector(print) Lic# Signature Date
Address of Property:
# SIDE LOCATION SOURCE Pb Hazard Type
(circle one) (circle one) (circle one) (circle one) (circle
A B C D Child's bedroom Rm# Window sill POS NEG INC A/M L
A B C D Child's bedroom Rm# Window Int sash Ext sash Exterior sill POS NEG INC M/I L
A B C D Child's bedroom Rm# Door edge Doorjamb POS NEG INC F L
A B C D Child's bedroom Rm# Baseboard Window casing Door casing POS NEG INC L
A B C D Child's bedroom Rm# Baseboard Win casing Door casing POS NEG INC L
A B D Kitchen ath Room # indow si Handrail Railing cap PO. NEG NC A/ L
A B C D Kitchen Bath Room# Window sill Handrail Railing cap POS NEG INC A/M L
A B C D Kitchen Bath Room# Window Int sash Ext sash Exterior sill POS NEG INC M/I L
A B C D Kitchen Bath Room# Window Int sash Ext sash Exterior sill POS NEG INC M/I L
A B C D Kitchen Bath Room# oor edge)Doorjamb PO. NEG INC F L
A B C Kitchen(Bath)Room# Door edg Door jamb POS NE INC )L
A(H)C D Interior hallway/bac,k�a(j Stair tread Door edge Qolor jamb POS EG INC F L
A B C D Interior hallway Window Int sash Ext sash Exterior sill POS NEG INC M/I L
(common area)
A B C D Interior hallway Stair tread Door edge Doorjamb POS NEG INC F L
(common area)
A B C D Interior hallway Window sill Handrail Railing cap POS NEG INC A/M L
(common area)
A B C D Interior stairway Stair tread Door edge Doorjamb POS NEG INC F L
common area)
A B C D Porch Stair tread Door edge Doorjamb POS NEG INC A/M L
A B C D Porch Railing cap Handrail Window sill below 5 POS NEG INC i A/M L
A B C D Exterior Cellar window sill POS NEG INC A/M L
A B C D Exterior Window sills below 5' POS NEG INC A/M L
A B C D Exterior—Main Entry Stair tread Door edge Doorjamb POS NEG INC F L
A B C D Exterior Main entry door casing POS NEG INC L
A B C D Exterior Siding Window casings Door casings POS NEG INC L
A B C D Garage/Outbuilding Siding Window casings Door casings POS NEG INC L
A B C D Garage/Outbuilding Window sills below 5' POS NEG INC A/M L
ABC D L,1i1125 roON �Uck(( IOose pak.l+ POS E INC L
A B D �{V� roOYI,) �dc POS NEG INC
A B C D POS NEG INC
A B C D POS NEG INC
Key for Hazard type: A/M=Access ible/Mouthable L= Loose F=Friction M/I=Moveable/Impact
Address of Property:
DISCLAIMER CONCERNING LEAD DETERMINATION REPORT
The information contained in this report concerning the presence of lead paint does not constitute a
comprehensive lead inspection. The surfaces tested represent only a portion of those surfaces that would be
tested to determine whether the premises are in compliance with the Massachusetts Lead Poisoning Prevention
Law(Massachusetts General Laws,chapter 111, sections 189A through 199B).
Serious lead poisoning hazards are created when materials containing lead paint are disturbed,unless
proper safety guidelines are followed. Therefore,Massachusetts's law and regulations require that:
Before deleading work begins, a comprehensive intial inspection must be performed, which identifies
lead hazards and qualifies approrpiate deleading options. Deleading of lead hazards must be performed
by an appropriately authorized person, including a licensed deleading contractor, a licensed lead-safe
renovator with moderate-risk deleading certification, and an owner/agent who is trained and authorized
to perform specific work as required under the Lead Law. Contact the Childhood Lead Poisoning
Prevention Program for additional information regarding deleading and authorization. Call toll free:
800-532-9571 or visit: www.mass.gov/dph/clppp. To find a list of licensed deleaders or lead safe
renovators certified to do moderate-risk deleading visit the Department of Labor Standards(DLS)at
www.mass.gov/deleading-and-lead-safety. Letters of Full Compliance will be withheld if
unauthorized deleading has occurred.
Deleading requirements include rules regarding notification, containment, occupancy restrictions,and clean
up requirements.Any deleading work done on the basis of this report will not qualify the property owner for
a state income tax credit,nor will the cost of such deleading be reimbursable under any state loan or grant
program. In order to qualify for such programs,the premises must first be subject to a comprehensive lead
paint inspection.
Because a child under six resides in this dwelling,the property owner may face criminal or civil liabilities
unless all lead paint violations have been corrected. This lead report cannot assure that the property owner
has met his or her obligations under the law.
It is unlawful for rental property owners to use the presence of lead as the basis for discrimination against tenants
or potential tenants with young children.