The URL can be used to link to this page

Home My WebLink AboutWest St. #115 - 2/17/2021Instructions 1. All sections of this form must be completed in order to comply with MassDEP notification requirements of 310 CMR 7.15 and Department of Labor Standards (DLS) notification requirements of 453 CMR 6.12 MassDEP Use Only Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Notification Form A. Asbestos Abatement Description 1. Facility Location: RESIDENCE a. Name of Facility MANSFIELD c. City/Town TRICIA GRANT g. Facility Contact Person Name Worksite Location: 2. Is the facility occupied? ry—' a. Yes 1— b. No 115 WEST ST b. Street Address MA 02048 0000000000 d. State e. Zip Code I. Telephone HOMEOWNER h. Facility Contact Person Title 1100341284 Asbestos Project # F Project Revision r Project Cancellation BASEMENT i. Building Name, Wing, Floor, Room, etc. 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner -occupied residential property of four units or less)? W a. Yes r' b. No 4. Blanket Permit Project Approval, if applicable: Date Received Approval ID # 5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable: 6. Asbestos Contractor: Approval ID # PETER GREIFER ENTERPRISES INC 78ORESERVOIRAVE #194 a. Name b. Address CRANSTON R 02910 4019464506 c. City/Town d. Stale e. Zip Code I. Telephone A0000241 It. Contract Type: I-J 1. Written 172. Verbal g. DLS License # 7. PETERDGREIFER ASO40460 a. Name of Contractor's On -Site Supervisor/Foreman b. DLS Certification # 8. PATRICIA EILEEN RILEY AM060297 a. Name of Project Monitor b. DLS Certification # 9. PROSCIENCE ANALYTICAL SERVICES INC AA000156 a. Name of Asbestos Analytical Lab b. DLS Certification # 10. 3/3/2021 3/4/2021 a. Project Start Date (MM/DD/YYYY) b. End Date (MM/DDNYYY) 9:00-4:00 N/A c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday 11. What type of project is this? J` a. Demolition fv� b. Renovation F c. Repair f- d. Other - Please Specify: Revised: 11/13/2013 Page t of4 Massachusetts Department of Environmental Protection - 100341284 '' BWP AQ 04 (ANF-001) Asbestos Project # Asbestos Notification Form r- Project Revision I' Project Cancellation A. Asbestos Abatement Description: (cunt.) 12. Abatement procedures (check all that apply): )✓ a. Glove Bag r b. Encapsulation r c. Enclosure r d. Disposal Only f` e. Cleanup f. Full Containment r g. Other - Please Specify: 13. Job is being conducted: 1J a. Indoors F b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 120 1. Linear Feet (Lin. Ft.) b. Boiler, Breaching, Duct, Tank Surface Coatings d. Pipe Insulation f. Spray -On Fireproofing h. Cloths, Woven Fabrics j. Insulating Cement 1. Lin. Ft. 2. Sq. Ft. 120 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq, Ft 15. Describe the decontamination systcan(s) to be used: THREECHAMBER 2. Square Feet (Sq. Ft.) c. Transite Pipe e. Transite Shingles g. Transite Panels i. Other - Please Specify: 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. 16. Describe the containerizatlon/disposat methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): LABELED ASBESTOS DISPOSAL BAGS 17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency: a. Name of MassDEP Official - b. Title of MassDEP Official c. Date of Authorization (MM/DD/YYYY) d. Waiver # e. Name of DLS Official f. Title of DLS Official g, Date of Authorization (MM/DD/YYYY) h. Waiver # 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this r a. Yes W b. No project'? Revised: 1 1 /13/2011 Pane 2 of 4 Note: Temporary storage of Asbestos containing waste material is only allowed at the place of business of a DLS licensed Asbestos contractor or a transfer station that is permitted by MassDEP and operated in compliance with Solid Waste Regulations 310 CMR 19.000 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Notification Form B. Facility Description 1. Current or prior use of facility: RESIDENTIAL 100341284 Asbestos Project # i— Project Revision I— Project Cancellation 2. Is the facility owner -occupied residential with 4 units or less? lv a. Yes r b. No TRICIA GRANT a. Facility Owner Name MANSFIELD c. City/Town N/A a. Name of Facility Owner's On -Site Manager N/A c. City/Town 115 WEST ST b. Address MA 02048 0000000000 d. State e. Zip Code f. Telephone N/A b. Address MA 00000 0000000000 d. e. State Zip Code f. Telephone 5 N/A N/A a. Name of General Contractor b. A N/A c. City/Town MA 00000 0000000000 d. State e. Zip Code f. Telephone BEACON MUTUAL g. Contractor's Worker's Compensation Insurer 7296 8/25/2021 h. Policy # i. Expiration Date (MM/DD/YYYY) 6. What is the size of this facility? 2400 2 a. Square Feel Is. # of Floors C. Asbestos Transportation & Disposal 1. Transporter of asbestos -containing waste material from site of generation: f" a. Directly to Landfill or iY b. To Temporary Storage Location/Transfer Station ASBESTOS CONTRACTOR PO BOX 10417 c. Name of Transporter d. Address CRANSTON R 02910 4019464506 e. City/Town T. State g. Zip Code h. Telephone 2. If a temporary storage location/transfer station is used, list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: SERVICE TRANSPORT a. Name of Transporter 301 OXFORD VALLEY RD b. Address YARDLEY PA 19067 8779999559 c. Cityfrown d. State e. Zip Code f. Telephone 111DRY11441k Page 3 of 4 '""' L Massachusetts Department of Environmental Protection -___ BWP AQ 04 (ANF-001) Asbestos bestos Project # Asbestos Notification Form i"" Project Revision f Project Cancellation C. Asbestos Transportation & Disposal: (coat.) 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: SERVICE TRANSPORT 28 PRIVILEGE ST a. Temporary Storage Location Name b. Address WOONSOCKET 14 02895 8779999559 c. City/Town d. State e. Zip Code I. Telephone 4. Name and location of final disposal site (asbestos landfill): MINERVA MINERVA ENTERPRISES a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA LANE c. Address WAYNESBURG CH 44688 3308663435 d. City/Town e. State I. Zip Code g. Telephone Note: Contractor must sign this form for DLS notification purposes D. Certification "I certify that I have personally examined the foregoing and am familiar with the information contained in this document and all attachments and that, based on my inquiry of those individuals immediately responsible for obtaining the information, I believe that the information is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." PETER GREIFER I.Name SUPERVISOR 3. Positionfri0e 4019464506 5. Telephone PO BOX 10417 7. Address Po 9. State PETER GREIFER 2. Authorized Signature 2/17/2021 4. Date (MM/DD/YYYY) ASBESTOS CONTRACTOR 6. Representing CRANSTON 8. City/Town 02910 10. Zip Code Revised: 11 / 13/2013 Page 4 of 4 Peter Greifer Enterprises, Inc. P.O. Box 10417 Cranston, RI 02910 (800) 582-5288 or (401) 529-3122 2/17/21 Mansfield Health Dept. 6 Park Row Mansfield, MA 02048 To whom it may concern, Ref: 115 West Street, DEN 100341284 Enclosed is your copy of the asbestos notification form for the above referenced project. Please call if you have any questions. Sincerely, Peter Greifer