HomeMy WebLinkAboutSo. Main St. #363 - 8/20/2010Important:
When filling out
forrns on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
1. All sections of this
form must be
completed in order
to comply with
DEP notification
requirements of 310
CMR 7.15
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100109811
Decal Number
A. Asbestos Abatement Description
1. a. Is this facility fee exempt - city, town, district, municipal housing aut n
residence of four units or less? (d]Yes ❑ No
b. Provide blanket decal number if applicable: Blanket t Decal Numb
2. Facility Location:
CUNNINGHAM 383 S. `� ^�_ MAIN ST._
a. Name of Facility b. Street Address
Mansfield l MBA 02048
— --i___ m__
c. Cityliown d. State e. Zip Code f.—ho Telepne Nuier-amb
3. Worksite Location:
BASEMENT
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
4. Is the facility occupied? [(] Yes [J No "
5. Asbestos Contractor:
ENGLAND SURFACE MAINTENANCE
850 WASHINGTON STREET
e
b. Address
MOUTH 02189
�7813372117 mY a
Town d. Zip Code
„'� „�
e. Telephone Number
6.
�PAUL W BROWN
7. LG.LEBLANC
ENVIROTEST LABS
8. —1 AnA nr n
M.
10. a. What type of project is this?
El Demolition [J Renovation
Z Repair ❑ Other, please specify:
11. a. Check abatement procedures:
Glove bag
❑ Enclosure
�] Cleanup
❑✓ Full containment
Encapsulation
❑ Disposal only
❑ Other, specify:
g. Contract Type: ❑ Written [] Verbal
b. Describe
b. Describe
12. Is the job being conducted: E,'] Indoors? ❑ Outdoors?
BMW
anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
�100109811
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed
encapsulated: _
140 —�— 00
a. Total pipes or ducts (linear ft) bl �To er su aces square
c. Boiler, breaching, duct, tank
L __J
L—„_,_J
d. Insulating cement
surface coatings
Lin. ft.
Sq�ft.
e. Corrugated or layered paper
i �40
I
f. Trowel/Sprayer coatings
pipe insulation
Lin. ft.
Sq. ft.
I-
g. Spray -on fireproofing
Linft.
---�
ft.
h. Transite board, wall board
I("
l�Sq.
1. Cloths, woven fabrics
Lip. R.
�
---� S ft:-OOt�ther,
please specify:
k. Thermal, solid core pipe
insulation
Lin. ft.
Sq. ft.
1. Specify
enclosed, or
14. Describe the decontamination system(s) to be used:
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
REQUIRED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
bb Ti—tle`—
d. DEP Waiver#
fat Title
h. DOS Waiver #
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes ❑✓ No
B. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No
3.
4.
Asbestos Notification Form • Pa e 2 of 3 ■
■ anf001 ap.doc • 10102
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
1.1
6. What is the size of this facility?
N
100109811
Decal Number
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM LLP—-----
a. Name of Transp_orter b. Address
c. City/Town a d. Zip Code e. Telephone Number
2. Transporter of asbestos -containing waste material from removalltemporary site to final disposal site:
RED TECHNOLOGIES
3.
Cl
e. State f. Zip Code
D. Certification
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos, 453 CMR 6.00 and
310 CMR 7.15, and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
d.
g. Telephone Number
IKEN FURTNEY I
b.
i. Zip Code _.�._.
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