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Town of Barnstable
Regulatory Services
BARN9 MASS. Richard Scali,Director
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�TEDMA'��• Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
LEAD DETERMINATION REPORT FORM
Date of Determination: '
Inspector:
License
Method Used Sodium Sulfide7Q Expiration date: 1 a —t
X-Ray Fluorescence Model:
Serial#: o 6q 1
Property Address: 2 w'S a C.
Nf S
Description of Property:
mgle family
Multi-family #units
Garage
Fence
Other structures
Age of Property: Pre-1978 I q)-v
-- -�Post- 978
Occupant: 52 0.V�1 I I� P0 V2�
Occupants d``g�r six year o age
C(n� T e of GQ DOB: f�--31- 17
DOB:
DOB:
Occupant's Telephone: -7 6
Property Owner(s):
Owner's Address:
TE S oN MA C>,, -pE5" I6 o
Owner's Telephone: o
Lead Hazards found? Yes No.
An X-ray fluorescence reading greater than 1.0 mg/cm2 or a gray or black reaction to sodium
sulfide indicates a dangerous level of lead and constitutes a positive determination.
Deleading should not be undertaken based on this report. A licensed lead inspector must
do a full inspection in order for you to qualify for a Compliance Letter. Deleading of lead
painted surfaces must be performed by an appropriately authorized person, including a
licensed deleading contractor, a licensed lead-safe renovator, and an owner/agent who is
trained to perform specific work as required under the Lead Law. Contact the Childhood
Lead Poisoning Prevention Program for additional information regarding deleading and
training.
BOH Determ Form
Revised I-05
Page 1 of 2
LOCATION SOURCE Pb
1. Childs bedroom(BR) 1"window. Interior stop Left side of neg
window
2. Childs bedroom(BR) lst Window.Interior stop right side of neg
window
3. Childs bedroom(BR) 1st Window sill Left side. Chipping paint neg
4. Childs bedroom(BR) I"Window sill right side. Chipping paint neg
5. Childs bedroom(BR) 2nd window.Interior stop Left side of neg
window
6. Childs bedroom(BR) 2nd Window. Interior stop right side of neg
window
7. Childs bedroom(BR) 2nd Window sill Left side. Chipping paint neg
8. Childs bedroom(BR) 2nd Window sill right side. Chipping neg
paint
9. Childs bedroom(BR) Door to bedroom panel area. Chipping neg
paint.
10. Childs bedroom(BR) Door to bedroom.Door stile. Chipping neg
paint
11. Childs bedroom(BR) Bedroom door door jam non-hinged side neg
12. Childs bedroom(BR) Base board trim neg
13. Hallway Base board trim neg
14. Hallway Baseboard trim near bathroom entrance neg
15. Bathroom Door panel. Chipping pant neg
16. Kitchen window. Interior stop Left side of window neg
17. Kitchen Window.Interior stop right side of neg
window .
18. Kitchen Window sill Left side. Chipping paint neg
19. Kitchen Window sill right side. Chipping paint neg
20. Kitchen Cabinet. Chipping Paint neg
21.
22.
23.
24.
25.
BOH Determ Form
Revised 1-05
Page 2 of 2
Town of Barnstable
Regulatory Services
Richard Scali, Director
* BAftNSfABL&
16 9. Public Health Division
r�D"AAA a Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REQUEST FOR DETERMINATION OF LEAD HAZARDS
AND ENFORCEMENT OF THE LEAD LAW
Date: 20]?
I llwflctt� �t(� ,re uest the (q Department
print name of occupant
of Public Health to inspect my residence or dwelling unit for lead paint. ,f
The address of this residence or unit:
Street and Apadment Number
--`'(, , Massachusetts.
City or Town Zip code
The telephone number to reach me there is:� /2 ) (L 3s- 14 7
Phone Number
The child (ren)under the age of six (6) years who reside(s) in this household is/are:
(1,41nia r ft l -AY-d
Was the residence built before 1978T 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
Iidence, h etermination hereby requested identifies lead hazards in violation of Massachusetts
f
1
BOH Request for Determination Revised 11/04
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's Childhood Lead Poisoning Prevention Program
conducts random audits of inspections conducted by private inspectors and risk assessments conducted by
private risk assessors following lead determinations. Such monitoring is performed to assure the quality of
services being provided to the public. By requesting this determination, 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.
ign�ature of Occupant
t
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BOH Reouest for Determination Revised 11/04