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49 Butler Street #1 (002) ;lam oAV CITY OF SALE1f, M SSACHUSET`TS BOARD OF HE iLLTH ��yW�I1�3L�:yigiGiLyi 98 WASH'LNGTON STREET,3RD FLOOR Pm-'.P—.m F'.t*h [. TEL.(979)741-18010 ROSERTAICCART I healthfa5alem-com D3S-iD GREENB:ILT.L[,Rs ACT NG MAYOR HF--kLTH AGENT LEAD DETERMINATION REPORT FORM St.# Stpqt Name t eet Type Unit i4 Ci Coke Date of Determination: Sodium Sulfide expiration date: Number of Rooms in Unit X-Ray Fluoresce e: Model: Serial#: Property Type: Owner: Owner Address: ❑Single Family Multi Family #of Units Contact Inform ation: Condominium #of Units Home built before 19 ' Yes , No ❑Day Care ❑Other LEAD HAZARDS? EJ Yes IR No Property Diagram/Unit Labels Floo (level within building of unit being inspected) C b B - ------------------------------ -------------------------- D ----------------------------- -------------------------- I�l ►- LUc�,�=t 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 before licensed or authorized individuals do the work in order for the unit to qualify for a Compliance Letter. In pector's Name License# Signat Date Page 2 of 3 nspector(print) f �Lic nature Date Address of Pro e : # SIDE LOCATION SOURCE Pb Hazard Type (circle one) (circle one) (circle one) (circle one) (circle) A B C@D Child's bedroom&/O im#?kYindow s' POS . G INC A L A B C D Child's bedroom&/OR Rm# Window Int sash /Ext sash/ Exterior sill POS NEG INC M/I L A BCD Child's bedroom&/OR oor edge Doorjamb POS &G INC FOL A B C D Child's bedroom&/OR Rm# Baseboard/Window casing/Door casing POS NEG INC L A B C D Child's bedroom&/OR Rm# Baseboard/Window casing/Door casing POS NEG INC L A D Kitchen/ at OR Room# indow sip Handrail Railing cap POS &INC A&C D itche /Bath OR Room# indow ill / Handrail/Railing cap PO E INC IM L A B C Kitchen/ at OR Room# indow Inti sas /Ext sash/ Exterior sill POS I& INC /I A B 5b Kitchen/ ath R Room# Window Int sash / xt sas / Exterior sill POS 'ED INC II L ABC itc en/Bath OR Roo Door edge / oorJamb POS EG INC F L A B Kitchen/Bath O Room# Door edge Doorjamb POS JEPNC F L Interior hallwa Stair tread / Door edge Door jam POS E INC F L Interior hallway A B C D Window Int sash /Ext sash /Exterior sill POS NEG INC M/I L qA B CC), erio allway tair trea / Door edge Doorjamb POS EG INC F� t ommon InOor hallway A B C D Window sill / Handrail / Railing cap POS NEG INC A/M L (common area) 1 A BCD (c or. aiA B COD area Stair tread/ o�edgeDoorjamb POS 9INC OF L A B C D Porch Stair tread/ Docrr edge /Door jamb POS NEG INC F L A B C D Porch Railing cap/Handrail/Window sill below 5' POS NEG INC A/M L A B C D Exterior Cellar window sill POS NEG INC A/M L l A B C D Exterior Window sills below 5' POS NEG INC A/M L A C D Btenor—Main Ent Stair tread / Door edge / oor jamffl POS EG INC F OL 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 A B C D "C', ; ,{ POS e6@ INC A B CD POS G INC A C D PO NEG NC BCD 2mt a- POS EG C Key for Hazard type: A/M=Accessible/Mouthable L=Loose F=Friction NIJ=Moveable/Impact Pb (lead)column: POS (positive for hazardous level of lead),NEG(negative, less than 1.0 mg/ Page 3 of 3 cmz), INC (inconclusive sodium sulfide result) . / f nspector(print) Lic# gnature I 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&/OR Rm# Window sill POS NEG INC A/M L A B C D Child's bedroom&/OR Rm# Window Int sash /Ext sash/ Exterior sill POS NEG INC M/I L A B C D Child's bedroom&/OR Rm# Door edge Door jamb POS NEG INC F L A B C D Child's bedroom&/OR Rm# Baseboard/Window casing/Door casing POS NEG INC L A B C D Child's bedroom&/OR Rm# Baseboard/Window casing/Door casing POS NEG INC L A B C D Kitchen/ Bath OR Room# Window sill Handrail Railing cap POS NEG INC A/M L A B C D Kitchen/Bath OR Room# Window sill / Handrail/Railing cap POS NEG INC A/M L A B C D Kitchen/Bath OR Room# Window Int sash /Ext sash/ Exterior sill POS NEG INC M/I L A B C D Kitchen/ Bath OR Room# Window Int sash /Ext sash/ Exterior sill POS NEG INC M/I L A B C D Kitchen/Bath OR Loom# oor edge / oor jamb POS G NC F L N ARC D Kitchen fatqOR Room# oor ed�/Doorjamb POS EG NC F L A B C D Interior hallway Stair tread / Door edge Doorjamb POS NEG 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/ Dodr edge /Door jamb POS NEG INC F L A B C D Porch Railing cap/Handrail/Window sill below 5' POS NEG INC 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 / Door jamb 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 POS G INC POs EG INC A B C D POS NEG INC A B C D POS NEG INC Key for Hazard type: A/M=Accessible/Mouthable L=Loose F=Friction M/I=Moveable/Impact Pb(lead)column: POS (positive for hazardous level of lead),NEG(negative, less than 1.0 mg/ Page 3 of 3 cm2), INC (inconclusive sodium sulfide result) Address of Pro;e i DISCLAIMER CONCERNING LEAD DETERMINATION REPORTS Serious lead poisoning hazards are created when materials containing lead paint are disturbed, unless proper safety guidelines are followed. If a child under six resides in this dwelling,the property owner may face criminal or civil liabilities unless all lead paint violations identified in a comprehensive lead inspection have been corrected. Therefore,the Massachusetts Lead Poisoning Prevention Law(Massachusetts General Laws, chapter 111, sections 189A through 19913)and regulations(105 CMR 460.000, Lead Poisoning Prevention and Control)require that before any deleading work can begin,the premises must first be subject to a comprehensive lead paint inspection. This inspection must be conducted by a Massachusetts fully licensed Lead Inspector. The Lead Determination report this disclaimer is attached to is NOT a comprehensive lead paint inspection report. Lead Determinations test only a small portion of those surfaces that must be tested to determine whether the premises are in full compliance with the Massachusetts Lead Poisoning Prevention Law. Once a Comprehensive Initial Inspection has been conducted,only a Licensed Deleader can do High-Risk Deleading, such as scraping or the use of caustics. Property owners, their agents, and Licensed Lead-safe Renovators may complete additional training to be licensed or authorized to do Low and Moderate-Risk Deleading. Owners and their agents should contact the Childhood Lead Poisoning Prevention Program(CLPPP)for more information. Lead-safe Renovators licensed by the Department of Labor Standards(DLS)should contact DLS regarding additional Moderate- Risk deleading training. Letters of Full Compliance will be withheld if either the inspection or authorization requirements are not met. It is illegal for rental property owners to discriminate against tenants or potential tenants with young children to avoid compliance with the lead paint law,or to retaliate against tenants for requesting a lead paint inspection. This document and all lead-related inspection, reinspection, and compliance documents must be provided to the current owner and must be transferred upon sale of the property along with the Property Transfer Notification. For rental properties,this document and all lead-related inspection,reinspection,and compliance documents must be provided to the current tenants and subsequent tenants. ALERT FOR FEDERALLY-ASSISTED PROPERTIES Please be advised that Massachusetts properties receiving federal assistance(such as HUD rehabilitation funds, Section 8 vouchers and funds, and others)must comply with both Massachusetts and Federal regulations. Lead hazard abatement or remediation activities, including paint stabilization,done based on the attached Determination report or on a HUD Inspection Report, neither of which is a comprehensive initial inspection,violates Massachusetts law. Such properties would NOT qualify for a Letter of Full Deleading Compliance. For more information, please contact the inspector who completed the attached Determination report, or the Childhood Lead Poisoning Prevention Program at 1-800-532-9571 or www.mass.gov/dph/cippp. Disclaimer Alert Revised 3/20 Page 1 of 3 The Commonwealth of Massachusetts `7� r Executive Office of Health and Human Services d Department of Public Health .'� Bureau of Environmental Health 5 Randolph St, Donovan Health Building Canton, MA 02021 MARYLOU SUDDERS CHARGES D.BAKER Phone: 617-624-5757 Fax: 617-624-5777 Governor Secretary KARYN E.POLITO TTY: 617-624-5286 MONICA BHAREL,MD,MPH Commissioner Lieutenant Governor Tel:617-624-6000 www.mass.gov/dph REQUEST FOR DETERMINATION OF LEAD HAZARDS AND ENFORCEMENT OF THE LEAD LAW Date: 03` _ 20, �� r 1, 4" 1-1t V I , request the Childhood Lead Poisoning (print name of o cupant) Prevention Program to inspect my residence or dwelling unit for lead paint The address of this residence or unit: S'�� .J� ��a� �"r 61ler-/l Street and Apt/Unit Number r4 b , MA The telephone City or Town SG,( e r7i Zip Code 0 number to reach me there is: ( ) Phone Number The child(ren)under the age of six (6) years who reside(s) in this household is/are: Name Birth date Name Birth date �'c. ° -0 Name Birth date Name Birth date Was the residence built before 19789 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. You may e-mail this form to Amie Lindenboim, at Amie.Lindenboim@massmail.state.ma.us; however please be aware that our e-mail is not secured for private information. Alternatively, you can fax it to her at(781) 774-6700 or mail it to her at the address below. CLPPP code enforcement inspectors must prioritize our poisoned child case investigations. When our caseload is heavy,you may experience a delay in services delivery. Amie Lindenboim DPH/CLPPP 5 Randolph St, Canton,MA 02021 Signature of Occupant CLPPP Form No.4,11-84 (BOHREQUEST.DOC) Parental Req.for Determin. Rev.6/99, 10/97,10/02,4/2011,2018,7/29/2019