3 ENGLISH STREET - DELEADING NOTIFICATION (002) Department of Public Health-Childhood Lead Poisoning Prevention Program Au G 2 9 2022
Deleading Notification CITY OF SALEM
Please complete all sections of this form clearly.Incomplete or Illegible forms will be returned. BOARD OF HEALTH
Lead Paint lnspector c r a
--�-- � License#�1t1 I Inspection Date f
Property Owner Uwars) � t�.n
Property Owner's Address Zip CodeCII 5`
Authorized person performing work- waC3 , -2 Lic#/Auth.# K 001
Address of authorized person S C n Zip Code i /
Telephone Number 14 S
Address where the work will be done:
Building Name(if any) /0 p, Floor j&tI "fie,
Street Address a pt No. 1 �+d 1
City Zip Code_C) +The property is a multi-family single family.
Deieading Methodist:
4 Making paint intact(high risk) ,, Making paint intact(moderate ❑ Applying vinyl siding on exterior
❑ Demolition risk) :1 Component removal(low risk
Scraping 7d Liquid encapsulant components)
Component removaureplacement Covering ❑ Other:
❑ Dipping ❑ Capping baseboards T
The work will begin on f f o�! and will finish by /~1W The work will be done in the am -Vpm or weekendS.
In Case of Emergency Contact iA wmr6 O(- 1QfeSoq MR.-V•1I
Daytime Phone $)O 1V 14 S Evening Phone 7L s g0 �t{
lag 843 303' - Sag -0�3 -,103
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 will be performing only those activities indicated above.All of the
information contained in this document is true and correct to theWbes�tf my k wledge and belief.
Date Z 2 Signed
The following people/agencies must be notified ten days before beginning work:
1. Occupants of the dwelling unit
All other occupants of the residential premises, if any work will be done in the common areas 1
3. Childhood Lead Poisoning Prevention Program,DPH Fax(781)774-6700
MWRHO
5 Randolph Street, Canton,MA 02021
4. Asbestos and Lead Program, DLS
19 Staniford St, 1' Floor, Boston,MA 02114 Fax(617)626-6965
Local Board of Health/Code Enforcement Agency
"If the home is on the State Register of Historic Places,call the MA Historical Commission at(6 1 71 727-8470.