58 BRIDGE STREET UNIT 3 LEAD DETERMINATION REPORT FORM 8-24-2022 >>UPLOAD LETTERHEAD IN THIS SPACE<<
LEAD DETERMINATION REPORT FORM
St.# Street Name Street Type Unit
1 1 -3
city Zip Code
7
Date of Determination:? 41 12022—
Sodium Sulfide expiration date: :1 116/202-2—
X-Ray Fluorescenc : Model: Serial#: Number of Rooms in Unit
Owners Name: LL Property Type:
Owner Address:l.S P.—t �r i $. ❑Single Family
p Ve'S. Multi Family #of Units
Contact Information: f 71 q-1t)_19K_ NCondominium #of Units
Home built before 1978? Kool Yes ❑No ❑Day Care ❑Other
LEAD HAZARDS? RYes ❑No
Property Diagram/Unit Labels
Floor#_1_—(level within building of unit being inspected)
C b
--------------------------- -------------------
D Uri;+ Url I"I'
n ' wt eIt 3
ILJIn -----3------------------- --- --— —
z" L Unit tth�
r
Z
S Uh 1- Win,
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/cmZ
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.
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Inspector'f Name License# ;i4ure Date
i
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LEAD DETERMINATION REPORT FORM
St.# Street Name Street Type Unit _
in s 3 1
city Zip Code
1 FOR o
Date of Determination: 1.262.2-
Sodium Sulfide expiration date: : L /2ev,7—
X-Ray Fluorescence: Model: Serial#: Number of Rooms in Unit
Owners Name: Jo-ol 5-prrn +i��: 1 1 �' Property Type:
Owner Address: �S D,��✓n_ ❑Single Family
Multi Family #of Units _
Contact Information: I - 'J 5 .5� Condominium #of Units
Home built before 1978? X Yes ❑No ❑Day Care ❑Other
LEAD HAZARDS? Yes ❑No
Property Diagram/Unit Labels
Floor# 2— (level within building of unit being inspected)
C b
B ------------------------------------ -------------------
3 3
- -Lit-
----- --------------------------
2 3
--------------------------------------------------------
Unj?� (phi111 -17 1 1 — I f
2
-- -------------------------------
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.
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Inspector'. Name License# Al Z
Signature Date
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LEAD DETERMINATION REPORT FORM
St.# Street Name Street Type Unit
1 13
citV Zip Code
q 70
Date of Determination: d /.t_.L/.2022—
Sodium Sulfide expiration date: :q /1.6 /2022- Q
X-Ray Fluorescence: Model: Serial#: Number of Rooms in Unit f
Owners Name: jall, 5 P "a,L.L _ Property Type:
El Single Family
Owner Address:
®Multi Family #of Units 7
Contact Information: 6. - 1 - ❑Condominium #of Units
Home built before 1978? Yes 0 No ❑Day Care ❑Other
LEAD HAZARDS? Yes ❑No
Property Diagram/Unit Labels
Floor# 3 (level witbin building of unit being inspected)
C b
ric D Uri;+ Uni-�
3 3
-2------------------------3------------------
(>� Wilt
--�---------------
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.
Inspector'i Name License# Signature Date
-JP aK94 D 4227 /2-tic -2z
Inspector(pri t) Lic# at Date
Address of Propert
# SIDE LOCATION SOURCE Pb Hazard Type
(circle one) (circle one) (circle one) (circle one) (circle)
A CC D Child's bedroom Rm# indow sill POS NEG INC 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 D Child's bedroom Rm#2 Door edge oor jamb POS EG 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 C D Kitchen Bath Room# Window sill Handrail Railing cap POS NEG INC A/M L
ABC D Kitchen t Room# indow silj Handrail Railing cap POS QLE9 INC L
g A B C Kitchen Bath oom# Windo Int sash Ext sash Exterior sill POS EI , INC II L
A B C D Kitchen Bath Room# Window Int sash Ext sash Exterior sill POS NEG INC M/I L
A B C Kitchen Room# Door edge oor jamb POS LJ INC �L
A B C D itchen Bath Room# Door edge < oor jam POS EG INC F L
7 A B C Interior hallway Stair tread Door edge oor jam POS INC 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 Di Interior hallway Stair tread Door edge Door jam POS 9 INC F
common areal
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 o c Stair tread Door edge <oor jam POS(9 INC A/M
A B C ) orc Railing cap Han ai Windowsill below 5 POS G INC A/M�
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
2 (9B C D JJIS POS E INC
if A B C(EJI POS INC
_�
PA
CD r POS 0 INCC(D POShC, INC
Key for Hazar e: _ I e/Mont able = oose F=Friction M/I=Moveable/Impact
412 13 Z' /2.02z
Inspector( +nt) Lic# na a Date
Address of Property: Y �[�'eG Anil t�
# 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 C D Kitchen Bath Room# Window sill Handrail Railing cap POS NEG INC A/M 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# Door edge Doorjamb POS NEG INC F L
A B C D Kitchen Bath Room# Door edge Doorjamb POS NEG INC 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 I 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 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
A C D or H / POS INC
VD {crior�{alj POS INC Q
�r "O ) OS NEG INC D POS NEG INC
Key for Hazard type: A/M=Accessible/Mouthable L=Loose F=Friction M/I=Moveable/Impact
Address of Property: .Sti-ret � � 3
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.
The Commonwealth of Massachusetts
2
Executive Office of Health and Human Services
? . Department of Public Health
Bureau of Environmental Health
250 Washington Street, Boston, MA 02108-4619
MARYLOU SUDDERS
CHARLES D. Secretary
BAKER MONICA BHAREL,MD,MPH
Governor Commissioner
KARYN E. Tel;e17-e24-6000
POLITO www.mass.gov/dph
Lieutenant
Governor
REQUEST FOR DETERMINATION OF LEAD HAZARDS
AND ENFORCEMENT OF THE LEAD LAW
Date:—20 P
request the Childhood Lead Poisoning Prevention
print name of occupant
Pry to inspect my residence or dwelling unit for lead paint:
The address of this residence or unit: -e
Street and Apt/Unit Number
Sclke- yl , MA 011--7 O The telephone
City or Town Zip Code
number to reach me there is: 0
Phone Number
F
The child (ren)under the age of six(6) years who reside(s) in this household is/are:
Maw NO-T,e -QOXX�Q N-2-go
Name Birth date Name Birth date
' C#'R-'► 9465ok.'^.o
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 detenninations. Such monitoring is performed to
assure the quality of services being provided to the public. By requesting this detennination,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 wstate.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 7t' floor
Boston, MA 02108
Signature of Occupant
CLPPP Form No.4,11-84 (BOHREQUEST.DOC)
Parental Req.for Determin.
Rev.6/99, 10/97,10102,4/2011