Deleading Notification Ri:Utivcv
Depatuncnl ul'Puhhc I lealth -f'hddhrsxl Lead Pol:on!n_L I'rc\ention Proo(3f1i 1 2 Z��a
Deleading Notification UU�wV
CITY OF SALEM
Please complete all sections of this form clerk. Incomplete or illcuihk forms will be r'eturrQQARD OF HEALTH
lx:uf Paint I[llpel'IUr li 1~R 1 el IrAL i)t M
_K S d I,cense y 3 b'c�/ Inspcebcm D:u. I -
Props rt\ (hN-n:r_ ( 0;v" /v 4) /�'%la<,�''T l/i�i Lr Y
rr 'I
' 3c r1 p
Pnpx rt. (h+ncr s Address�� SC[� ,uR �D �7
4(' k'- jAt7 ;Ai[ L,c \uth
Authnnred pcm n perfitrming murk. L U �1 +} ✓C-�.i y "- Zip (odc D I 1!y_-
Address of authonmd person !S 5C4 .uNn
Tcicph(n,cNumNr(?7J)=�2 7- 617
Address ++here die aurk mdl hN:done ! 7 - Pl+wr f
HulldingNarncofam1 .J7 L 0,eL ! S l } AptNn ,ci0w_1
Street Address-J3 f}/4 L. r( 5 r �k m xn+ u a Muhl anu.lc f:unth
( itN 5hc-c f+ __.--�pci��L47D f X --
Deleadine\tethodls)i
❑ A ,ng u (In s,dum ,cNtcnir
• Matkjog pautt uitact(high nskI Makn,g paial oitaa Innxicrat( o ( ' h MIXInenl rcmoNa] (ION+ nsk
• Demolitionnsk l
/ 1 iquid encapsutant components)
• Scrapmu, u Other
p (""omponent rcmoNal replaccmen f Co%c rin.P.s•M nfs
:7 Dippinit to (app - -
The murA NNdI beem on /o l�'l and Ns,ll finish b\ 7 :31 /f The nark ++dl t?c dine in the K an, j*�rn, ur X %%eekends
Infuse of Cmcric i:N �UIMV l t L. V---
I)a\nnlc Phone_�7 d 'l 0 I,FY 5 F'.icmrtp Phone
The Properly Owner must cnmplece and sign the futlowiny infurmalion:
ecnif% that onls authonucd iIcrsovis \\ho hair .+,a,plicd NN,th the training wquircmcnis of the Massachusetts I cad Poisoning
Pre wntinri and Control Re cul:niutis. 1!!� C\IR tf-A,(110 NN dl conduct delcaul,ng NNork I lurthc, cellil% that the authonvvd
pets(ni(s1 roll not e\ceed the .cuf,e of his+hct autbonl\ and mill bC perthm,m� onk those acuities ndtcwcd,ib+nc All of tlu
!nlurn,.'nion contaimd in this dmumcnt,s true ad,d correct tv di;best ii(nit l.nescledG:and M:Imf
Dale G/SJ! ZU:f Signed 7
The foil++77owiln>Z people+akencien mull be notified Irn days before IxYunink cork:
1. Oecuµaits of the dm0ling unit
' All ottwr occupants of the residential ptrnusN.'�. if am mots, still lie done in the axnmon areas
Chddhtxxf Lead Poisoning, PtCNenUUri I'rogrvu. DP}{
Fa\(7> 1) 77 t-r.70i
M\%;RHo
r, Randolph Street. (-anon. %I.A
4 Ashcstos and 1 sad Program. DLS }a\ Ih 171 62h-h4hi
14 Stand'rd tit I" }IixNr BON10n. MA 1121 to
Local Hatrd of I Icallh;Code Enfoiccmcnt :\gale+
• It the Bunk 11 nit the ,laic Ria;rstcr of Heston\ Pla+cs-:all Ilk m k Histonc:il t'amm,sswn:u ibl'i"-->t-1'n