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Home My WebLink AboutChauncey # 136 - 9/29/2020AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1223608 Page 1 of 4 Massachusetts Department of Environmental Protection 1100333910 BWP AQ 04 (ANF-001) Asbestos Project# 5, Asbestos Notification Form 11 Project Revision Project Cancellation Instructions 1. All sections of this form most be completed in order to comply with MassDEP notification requirements of 310 CMR 7.15 and Debarment of Labor Standards (DLS) A. Asbestos Abatement Description 1. Facility Location: _—-- DEF70S_ __— ._.._ a. Name of Facility MANSFIELD _ _ _::EVJ MA_, C. City/rown d. State g. Facility Contact Person Name Worksite Location: 2. Is the facility occupied? is a. Yea ``II b. No L36 CHAUNCY STREET_-_ b. Street Address 02046 I W000-000ii e. Zip Code I. Telephone X _ h. Facility Contact Person Title (EXTERIOR __ 1 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 [I ] b. No notification requirements 4. Blanket Permit Project Approval, if applicable: of 453 CMR 6.12 MassDEP Use Only -- Date Received 5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable: 6. Asbestos Contractor: Approval ID # -1 Approval ID # NEW ENGLAND SURFACE MAINTENANCE LLP - - ,- 650 WASHINGTGN ST a. Name b. Address ''11 WEYMOUTH _-__- -- LMA �] (02189 c. Cityll own d. State tt e. Zip Code f. Telephone h. Contract Type �JI1. Wntten�f (_l2_Verbal) g. OILS License # 7 IJOSE VILL_ALTA _ a. Name of Contractors On -Site Supervisor/Foreman 8. IJEFF HILL a. Name of Project Monitor 9 IENVIROTEST LABORATORYINC a. Name of Asbestos Analytical Lab 10 [09/2a/2ozo ... a. Project Start Date (MM/DD/YYYY) 84 c. Work Hours - Monday Through Friday 11. What type of project is this? b. OILS Certification # AM000203 b. OILS Certification # b. OILS Certification # os/zs/zozo b. End Date (MM/DD/YYYY) d. Work Hours - Saturday & Sunday ".i a. Demolition i _ � b. Renovation "i c. Repair r/1 d. Other - Please Specify (EXTERIOR SHINGLES 12, Abatement procedures (check all that apply): IF a. Glove Bag 101 1I b. Encapsulation I1 11c. Enclosure i j ] d. Disposal Only 19 e. Cleanup [I_;i If. Full Containment rp/il g. Other - Please Specify EXTERIORSHINGLES l https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOI.aspx 9/15/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1223608 Page 2 of 4 13. Job is being conducted: (I a. Indoors 1JI1 b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: 1. Linear Feet (Lin. Ft.) 2. Square Feet (Sq. Ft.) b. Boiler, Breaching, Duct, Tank L_,-� II Surface Coatings 1. Lin. Ft. 2. Sq.-Ft. d. Pipe Insulation I. Spray -On Fireproofing It. Cloths, Woven Fabrics 1. Lin. Ft. 2. Sq. Ft. I_ _ _- 1. Lin. Ft. J I _=_a 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft. c. Transits Pipe E 1 1 1. Lin. Ft. 12. Sq. Ft. e. Transits Shingles I-. 1. Lin. Ft. 2. Sq. Ft. g. Transite Panels 1. Lin. Ft. 2. Sq. Ft. i. Other - Please Specify: I. insulating Cement ..____71200o _,.-� 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft._ 15. Describe the decontamination system(s) to be used: 16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency: a. Name of MassDEP Official c. Date of Authorization (MM/DD/YYYY) -I e. Name of DLS Official b. Title of MassDEP Official d. Waiver # f. Title of DLS Official g. Date of Authonzation(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 a. Yes`Wlb. No project? B. Facility Description 1. Current or prior use of facility: 2. Is the facility owner -occupied residential with 4 units or less? jd) a. Yes F b. No 3. IDEFTOS 1138 CHAUNCY STREET a. Facility Owner Name b. Address LMANSFIELD - MA,_- CO2043 _ � 10001 c. City/Town d. State e. Zip Code f. Telephone 4 . - _.-_...._ � rx _- a. Name of Facility Owner's On -Site Manager b. Address x Ma oC 0000 I_._1 _ 000 000 0000 c. City/Town d. State e. Zip Code f. Telephone 1 Ix -a. Name of General Contractor b. Address https:Hedep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOI.aspx 9/15/2020 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #1223608 Page 3 of 4 I �^^^_ 1 looaoo ) C000_00o0000 c. City/Town d. State e. Zip Code f. Telephone g. Contractor's Worker's Compensation Insurer X. � 101/01/2021 h. Policy # L Expiration Date (MWDD/YYYY) 6. What is the size of this facility? a. Square Feet b. # of Floors Note: Temporary storage of Asbestos containing C. Asbestos Transportation & Disposal waste material is only 1. Transporter of asbestos -containing waste material from site of generation: allowed at the place of business of a DLS a. Directly to Landfill or b. To Temporary Storage Location/Transfer Station licensed Asbestos contractor or a transfer — - --" INEW ENGLAND SURFACE MAINTENANLLP 850 WASHINGTON STREET _) — _CE ..... __ station that Is permitted c. Name of Transporter d Address by MassDEP and WEYMOUTH IMA � 02189 1 f781-337 2117 operated in compliance _ _ __j _— with Solid Waste e. City/Town I. State g. Zip Code h. Telephone Regulations 310 CMR 19.000 Note: Contractor must sign this forth for DLS notification purposes 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: F ED TECHNOLOGIES - t0 NORTHWOOD DRIVE a. Name of Transporter b. Address BLOOMFIELD _I ICT_ _, r06002 _ „� L,860-2t82428 d. State e. Zip Code f. Telephone c. City/Town 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: (RED TECHNOLOGIES_ a. Temporary Storage Location Name PORTLAND _ . _._ . _l ICT__-I c. City/Town d. State k03 PICKERING STREET b. Address I06480 �860342 1022_ e. Zip Code I. Telephone 4. Name and location of final disposal site (asbestos landfill): (MINERVA ENTERPRISES MINERVA a. Final Disposal Site Name b. Final Disposal Site Owner Name 9000 MINERVA ROAD c. Address LAYNESBURG _. _� IOH7_ I 144688 ,_ �330=6683435 d. City/Town 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 e. State I. Zip Code g. Telephone FUR `KEN TNEY,- _ � (KEN FURTN_EY t. Name 2. Authorized Signature (PARTNER _ 09/15/2020 3. Position/Title 4. Date (MM/DD/YYYY) I78t 337.2117 - � INESM LLP 5. Telephone 6. Representing r50WASHWGTONSTREET WEYMOUTH 1 7. Address 8. City/Town MA ..._. ___ _....__..I 9. State 02189 10. Zip Code https:Hedep.dep.mass.gov/eDEP/WebForms/AsbestosBWPANF001.aspx 9/15/2020 AQ 04 -Asbestos Removal Notification Form ANF-001- Transaction #1223608 Page 4 of 4 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." https://edep.dep.mass.gov/eDEP/WebForms/Asbestos/BWPANFOOl.aspx 9/15/2020