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3 ENGLISH STREET - DELEADING NOTIFICATION
RE CEIVED Department of Public Health-Childhood Lead Poisoning Prevention Pro am DeleadEag Notification i�AY 2 6 2022 CITY OF SALEM Please complete all sections of this form clearly.Incomplete or illegible forms will be returGOIgRD OF HEALTH Lead Paint Inspector C C �f) License#,N*-3&A Inspection Date Property Owner Properiy Owner's Address 1 - Zip Code (3 J Authorized person performing work- E&l 'c) MrrA,,ne7z Lac#/Auth_# 0S Address of authorized person 15 7aP Code_0j Telephone Number d6j 'O 1 V 1 Address where the work will be done: Building Name(if any) 11 IJ— Floor , Street Address F-aQ17eAN trk AlDt No. 1 qL16 a6 ; City _ lRlnn Zip Code(j The property is a multi-family single family. Deleadine Pdethod(s): o Making paint intact(high risk) Making paint intact(moderate ® Applying vinyl siding on exterior ❑ Demolition risk) ® Component removal(low risk ❑ wing it Liquid encapsulant components) a Component removal/replacement ❑ Covering ❑ Other._ ❑ Dipping fff Capping baseboards The work will begin on 6l lal--Ae!qmd will finish by_k/_ The work 4vill be done in the dam_Xjpm or weekends. In Case of Emergency Contact _©t I tdA 41e--'z- Daytime Phon �tl _ Evening Phone - ' The Property Owner must complete and sign the following information: I certify that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning Prevention and Control Regulations, 105 CMR 460-000,will conduct deleading work.I further certify that the authorized person(s)will not exceed the scope of his/her authority and gill be performing only those activities indicated above.All of the information contained in tins document is true and correct to the best of my knowledge and belief. Date �/ 01 � Signed The following people/agencies must be notified ten days before beginning work: i. Occupants of the dwelling unit 2. All other occupants of the residential premises,if any work will be done in the common areas a. Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700 MW-RHO 5 Randolph Street, Canton,MA 02021 4. Asbestos and Lead Program,DLS 19 Staniford St; If"Floor,Boston,NIA 02114 Fax(617)626-6965 5. Local Board of Health/Code Enforcement Agency *If the home is on the State Register of Historic Places,call the MA Historical Commission at(617)727-8470.