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:	$      	

RRP w/additional Moderate Risk Training	       	Authorization #	 MR-      	
		Issuance Date:	   /      /   	
Moderate Risk Deleader (owner/agent)	       	Authorization #	      - OMAM	
		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 #	      - 	 OL AL
 OE AE
 OB AB	
 			Issuance Date:	   /      /   		

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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