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HomeMy WebLinkAboutMiscellaneous - 1122 Great Pond Road 1122 Great Pond Road 7-09-202 10:35AM FROM ALPINE ENVIRONMENTAL 978 250 0565 P. 4 :I it Department of public Health/Department of Labor&Workfcf ce Development ! i Fa14ia � �j� NOTIFICATION OF DELEADING WORK 1 All sectloas of this form must be completed in order to comply with the notification requirements of M.G.L.C.111§197, 454 CMR 22.00 and 105 CMR 460.000,as most recently amended j it Contractor performing protect KC3C\c&6 �A 4 VQ N- License Date G' Lead Palot Inspector\1p�l1 lGC�i2a I Date of Inspection ZS 1 SU I License#-t- :p.Date ADDRESS OF PROJECT: Street Address _ INitmuer r1s A 1�;1;1�,, Propervy Owner l�`CY1F`ti i` �__ ---- Address iL Telephone Number a Deleading Method: (rWet/Dry ScrapingL Heat CUD Liquid Encapsulunt L)emolitlt)n Caustics Replacement , 1! f'"Ckher'celw--ed,please explain I I �I ]I , \ 1 vv 'I Check one: Dwelling is multi-family Single-family _ Otho Start Date I !t"ltl c7 Completion Date ::'hen-will::or—,`..-dont: :nn Q DNA 4C� (3p'.cL�, Proiect Sunervttor Namet v it License#_p� `� ESP•bate Worker's Compensation Policy Number U)UkcG4-C7c� Carrier'1� Citcar\ LL.�t�:C 1� In ease of cy contact tel.#_(�1 r`ZJ emen 1"�Ui`U�O FaG.�\�., G© !'�.��� (Contractor's Representative) j I'L n.newel- »NA�r' i] :J �j The undersigned hereby states.ander tie pains and penalties of penury,that helshe Ass read and understood the Comn�t►oweaith of Massachusetts Deleading Regulations,454 CMR 22.00,and the Lead Poisoning Prevention and Control Regulations,105 J�MR 460.000,and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. 3' I 6 � !' Date__ It -� tv v '�1sed /1Y"�'=w (\Q_ �, �1.l` In 1f�\W � company Namei ' !� �. ;`1�-=.�i �. ddresf v (�ro� ce p �v� � 1 , Che\c�c� o� yr4 otSdLj Telephone Number ?-W d'740 � O Y.GRD i JI I j i�