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Department of Public Health - Childhood Lead Poisoning Prevention Program Deleading Notification Please complete all sections of this form clearly. Incomplete or illegible forms will be returned* Lead Paint Inspector License Inspection Date Property Owner Authorized person performing work Lic /Auth. Address of authorized person Zip Code Telephone Number Address where the work will be done Building Name if any Floor Street Address Apt No* City Zip Code The property is a multi-family single family. Deleading Method s Making paint intact high risk Demolition Scraping Component removal/replacement Dipping risk Liquid encapsulant Covering Capping baseboards Applying vinyl siding on exterior components Other The work will begin on // and will finish by //. The work will be done in the am pm or weekends. In Case of Emergency Contact Daytime Phone 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 will be performing only those activities indicated above. All of the information contained in this document is true and correct to the best of my knowledge and belief* Date Signed The following people/agencies must be notified ten days before beginning work 1. Occupants of the dwelling unit 2. All other occupants of the residential premises if any work will be done in the common areas 3. Childhood Lead Poisoning Prevention Program DPH MWRHO Fax 781 774-6700 5 Randolph Street Canton MA 02021 4. Asbestos and Lead Program DLS 19 Staniford St 1st Floor Boston MA 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. Incomplete or illegible forms will be returned* Lead Paint Inspector License Inspection Date Property Owner Authorized person performing work Lic /Auth. Address of authorized person Zip Code Telephone Number Address where the work will be done Building Name if any Floor Street Address Apt No* City Zip Code The property is a multi-family single family. Address of authorized person Zip Code Telephone Number Address where the work will be done Building Name if any Floor Street Address Apt No* City Zip Code The property is a multi-family single family. Deleading Method s Making paint intact high risk Demolition Scraping Component removal/replacement Dipping risk Liquid encapsulant Covering Capping baseboards Applying vinyl siding on exterior components Other The work will begin on // and will finish by //. Deleading Method s Making paint intact high risk Demolition Scraping Component removal/replacement Dipping risk Liquid encapsulant Covering Capping baseboards Applying vinyl siding on exterior components Other The work will begin on // and will finish by //. The work will be done in the am pm or weekends. In Case of Emergency Contact Daytime Phone 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. .

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