Deleading Invoice Form PDF Details

The Deleading Invoice form serves as a critical document within the framework of public health and labor regulations, specifically addressing the meticulous process of removing lead-based paint from residences and buildings. It requires detailed information from the individual or company performing the deleading work, including their name, contact details, and the address where the deleading occurred. The form mandates an affirmation that all deleading and cleanup efforts adhered to the stringent guidelines set forth by the Department of Labor and Workforce Development’s Regulations, 454 CMR 22.00, as well as the Childhood Lead Poisoning Prevention Program’s Regulations, 105 CMR 460.000. Moreover, it delineates sections for deleading contractors and moderate to low-risk deleaders, distinguishing between them based on authorization or license status, and outlines specific deleading methods employed—ranging from scraping and encapsulation to replacement and covering. It further documents the premises and components treated, the start and finish dates of the deleading work, and the costs incurred. The form underscores the significance of keeping these documents intact and provides a contact point for queries, thereby facilitating a structured approach to lead abatement efforts aimed at safeguarding public health while ensuring compliance with regulatory standards.

QuestionAnswer
Form NameDeleading Invoice Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmassachusetts invoice print, deleading invoice full compliance, deleading form online, deleading invoice template

Form Preview Example

DELEADING INVOICE

Please completely and clearly fill out appropriate information:

Name (print)

 

Telephone

(

)

-

Company:

 

Work/Cell

(

)

-

Address:

 

Zip Code

 

 

 

Address of Deleading Work

 

Zip code

 

 

 

I hereby attest that all deleading activities and clean up were done in accordance with the Department of Labor and Workforce Development’s Regulations, 454 CMR 22.00 and the Childhood Lead Poisoning Prevention Program’s Regulations, 105 CMR 460.000.

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only complete section reflecting your authorization/license status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deleading Contractor

 

 

 

 

 

 

 

 

 

 

 

License#:

DC

 

 

Exp. Date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DS

 

 

 

 

 

 

 

 

Deleading Methods:

 

Scraping

 

 

Demolition

Power Sanding

 

 

 

Caustics

 

 

 

 

 

 

Heat Gun

 

 

Replacement

Covering

 

 

 

Making Intact

 

 

 

 

 

Liquid Encapsulation

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

Work was done in the following rooms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work was done on the following types of components:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start Date:

/

/

 

 

 

Finish Date:

/

/

 

 

Cost: $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorization # MR-

 

 

RRP w/additional Moderate Risk Training

 

 

 

 

 

 

 

 

 

Issuance Date:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorization #

-

OM

AM

Moderate Risk Deleader (owner/agent)

 

 

 

 

 

 

 

 

 

 

Issuance Date:

 

/

/

 

Deleading Methods:

 

Replacement

 

 

Making Intact (interior)

 

 

Capping Baseboards

 

 

 

 

 

 

Covering

 

 

 

Making Intact (exterior)

 

 

Liquid Encapsulation

 

 

Work was done in the following rooms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work was done on the following types of components:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Start Date:

/

/

 

 

 

Finish Date:

/

/

 

 

Cost:

$

 

 

 

(Doesn’t Include Owner’s Labor)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Low Risk Deleader (owner/agent)

Authorization #

 

-

 

Issuance Date:

/

/

OL AL OE AE OB AB

Deleading Methods:

 

Covering

 

 

 

 

Liquid Encapsulation

Capping Baseboards

 

 

 

Replacement (ONLY doors, cabinet doors, shutters, shelves not affixed, drawers, windows on hinges)

Work was done in the following rooms:

 

 

 

 

 

 

 

 

 

Work was done on the following types of components:

 

 

 

 

 

 

 

Start Date:

/

/

 

Finish Date:

/

/

 

Cost: $

 

(Doesn’t Include Owner’s Labor)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Questions? Call the Department of Public Health at 1-800-532-9571.

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