HomeMy WebLinkAboutDean St. # 65 - 9/14/2020Instructions 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
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
A. Asbestos Abatement Description
I. Facility Location:
RESIDENCE
a. Name of Facility
MANSFIELD
c. City/Town
RICHARD FRANK
g. Facility Contact Person Name
Worksite Location:
2. Is the facility occupied? l✓ a. Yes 1-'b. No
65 DEAN STREET
b. Street Address
MA 02048 0000000000
d. State e. Zip Code I. Telephone
OWNER'S NEPHEW
h. Facility Contact Person Title
100333885
Asbestos Project #
r Project Revision
j` Project Cancellation
ATTIC
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)? % a. Yes r- b. No
MassDEP Use Only
4. Blanket Pennit Project Approval, if applicable:
Date Received Approval ID #
5. Non -Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID #
6. Asbestos Contractor:
PETER GREIFER ENTERPRISES INC
a. Name
CRANSTON
c. City/Town
AC000241
g. OILS License #
7 PETERDGREIFER
78ORESERVOIRAVE #194
b. Address
Po 02910 4019464506
d. State e. Zip Code f. Telephone
h. Contract Type: Wo 1. Written T 2. Verbal
a. Name of Contractor's On -Site Supervisor/Foreman
ASO40460
b. DLS Certification If
8. PATRICIA EILEEN RILEY AM060297
a. Name of Project Monitor b. DLS Certification If
9 ENVIRO-SAFE ENGINEERING
a. Name of Asbestos Analytical Lab
10.
9/29/2020
a. Project Start Date (MM/DD/YYYY)
AA000131
b. DLS Certification If
10/5/2020
b. End Date (MM/DD/YYYY)
8:30-3:30 N/A
c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday
11. What type of project is this?
I-- a. Demolition W b. Renovation f- c. Repair I`" it. Other - Please Specify:
Revised: 11/13/2013 Page I of
Massachusetts Department of Environmental Protection 100333885
BWP AQ 04 (ANF-001) _- Pro _ _—
Asbestos ject #
Asbestos Notification Form f-- project Revision
Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
r a. Glove Bag lv b. Encapsulation r- c. Enclosure
f— d. Disposal Only f"
e. Cleanup
fv f. Full Containment IY g. Other - Please Specify: REMOVE VERMICULITE
FROM ATTIC
13. Job is being conducted: % a. Indoors i b.
Outdoors
14 a. Total amount of each type of asbestos Containing
materials (ACM) to be removed,
enclosed, or
encapsulated:
1400
1. Linear Feet (Lin. Ft.)
2. Square Feet (Sq. Ft.)
b. Boiler, Breaching, Duct,
c. Transite Pipe
Tank Surface Coatings 1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
d. Pipe Insulation
e. Transite Shingles
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
f. Spray -On Fireproofing
g. Transite Panels
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
It. Cloths, Woven Fabrics
i. Other - Please Specify:
1. Lin. Ft. 2. Sq. Ft.
j. Insulating Cement
VERMICULITE
1400
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
15. Describe the decontamination system(s) to be used:
"=0i0085Ie10
16. Describe the containerization/disposal methods tocomply 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
It. Date of Authorization (MM/DD/YYYY)
f. Title of DLS Official
h. Waiver#
18. Do prevailing wage rates as per M.G.L, c. 149, § 26, 27 or 27A—F apply to this IW a. Yes ry b. No
project?
Revised 11/11/9,011
Pnue 9 of'4
Massachusetts Department of Environmental Protection �100333885
BWP AQ 04 (ANF-001)
LF-,1-
Asbestos Project #
Asbestos Notification Form r Project Revision
r Project Cancellation
B. Facility Description
L Current or prior use of facility: RESIDENTIAL
2. Is the facility owner -occupied residential with 4 units or less? W a. Yes F b. No
3 WILLIAM O'HARE 65 DEAN STREET
a. Facility Owner Name b. Address
MANSFIELD MA 02048 5083397883
c. City/Town d. State e. Zip Code f. Telephone
4 N/A N/A
a. Name of Facility Owner's On -Site Manager b. Address
N/A MA 00000 0000000000
c. City/Town d. State e. Zip Code f. Telephone
5 N/A N/A
a. Name of General Contractor b. Address
N/A MA 00000 0000000000
C. City/Town 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)
1400 1
6. What is the size of this facility?
a. Square Feet b. # of Floors
Note: Temporary
C. Asbestos Transportation & Disposal
storage of Asbestos
p p
containing waste
1. Transporter of asbestos -containing waste material from site of
material is only
generation:
allowed at the place
r a. Directly to Landfill or W b. To Temporary Storage Location/Transfer Station
of business of a DLS
licensed Asbestos
contractor or a transfer
SERVICE TRANSPORT 301 OXFORD VALLEY RD
station that is
c. Name of Transporter d. Address
permitted by
MassDEP and
YARDLEY PA 19067 8779999559
operated in
e. City/Town f. State g. Zip Code h. Telephone
compliance with Solid
Waste Regulations
310 CMR 19.000
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 301 OXFORD VALLEY RD
a. Name of Transporter b. Address
YARDLEY PA 19067 8779999559
c. City/Town d. State e. Zip Code I. Telephone
Revised:I1/13/2013 Page 3 of
4,
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
I1-- --- -
85
I
Asbestos Project #
r Project Revision
Project Cancellation
C. Asbestos Transportation & Disposal: (cont.)
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 R 02895
8779999559
c. City/Town d. State e. Zip Code
I. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA ENTERPRISES
a. Final Disposal Site Name b. Final Disposal Site Owner Name
9000 MINERVA LANE
c. Address
WAYNESBURG ON 44688
3308663435
d. City/Town e. State f. Zip Code
g. Telephone
Note: Contractor must
sign this form for DLS
notification purposes
D. Certification
PETERGREIFER
PEfERGREIFER
"I certify that I have personally 1. Name
2. Authorized Signature
examined the foregoing and am SUPERVISOR
9/14/2020
familiar with the information
3. Position/Title
4. Date (MM/DD/YYYY)
contained in this document and
all attachments and that, based 4019464506
ASBESTOS CONTRACTOR
on my inquiry of those 5. Telephone
6. Representing
individuals immediately PO BOX 10417
CRANSTON
responsible for obtaining the 7. Address
8. City/Town
information, I believe that the p
02910
information is true, accurate, and
9. State
10. Zip Code
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."
Revised: 11/13/2013 Paee 4 of 4
Peter Greifer Enterprises, Inc.
P.O. Box 10417
Cranston, RI 02910
(800)582-5288 or (401)529-3122
9/ 16/20
Mansfield Health Dept.
6 Park Row
Mansfield MA 02048
To whom it may concern,
Ref: 65 Dead St. DEP#100333885
Enclosed is your copy of the asbestos notification form for the above referenced project.
Please call if you have any questions.
Sincerely,
Peter Greifer