HomeMy WebLinkAboutWest St. #244 - 6/21/2021Peter Greifer Enterprises, Inc.
P.O. Box 10417
Cranston, RI 02910
(800)582-5288 or (401)529-3122
6/21/21
Mansfield Health Dept.
6 Park Row
Mansfield, MA 02048
To whom it may concern,
Ref: 244 West St. DEP#100348134
Enclosed is your copy of the asbestos notification form for the above referenced project.
Please call if you have any questions.
Sincerely,
Peter Greifer
Instructions 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
244 WEST ST
a. Name of Facility
b. Street Addr
MANSFIELD
MA 02048
c. City/Town
d. State e. Zip Code
MICHAEL BAILEY
HOMEOWNER
g. Facility Contact Person Name
Woiksite Location:
2. Is the facility occupied? W a. Yes I - b. No
0000000000
I. Telephone
In. Facility Contact Person Title
1100348134
Asbestos Project #
).... 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)? ry a. Yes i' b. No
4. Blanket Permit 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
780RESERVOIRAVE #194
a. Name
b. Address
CRANSTON R
02910 4019464506
c. City/Town d. State
e. Zip Code L Telephone
AC000241
h. Contract Type: 1✓. 1. Written r 2. Verbal
g. OILS License #
PETERDGREIFER
ASO40460
?
a. Name of Contractor's On -Site Supervisor/Foreman
b. OILS Certification #
PATRICIA EILEEN RILEY
AM060297
8
a. Name of Project Monitor
b. DLS Certification If
PROSCIENCE ANALYTICAL SERVICES INC
AA000156
9.
a. Name of Asbestos Analytical Lab
b. DLS Certification #
10.
7/6/2021 7/7/2021
a. Project Start Date (MM/DD/YYYY) b. End Date (MM/DD/YYYY)
9:00-4:00 N/A
c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday
I I. What type of project is this?
r a. Demolition fvv_� b. Renovation I"- e. Repair I` it. Other - Please Specify:
Revised: 11/13/2013 Page I of
Ll�
'
�t
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)�._Asbestos
Asbestos Notification Form
-- - . 7]
100348134__
Project
r` Project Revision
r Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
rV a. Glove Bag r b. Encapsulation r c. Enclosure r d. Disposal Only r
e. Cleanup
r f. Full Containment r g. Other - Please Specify:
13. lob is being conducted: F/ a. Indoors r b. Outdoors
14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed,
enclosed, m
encapsulated:
log
1. Linear Feet (Lin. Ft.) 2. Square Feet (Sq. Ft.)
b. Boiler, Breaching, Duct, c. Transite Pipe
Tanlc Surface Coatings 1. Lin. Ft 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
d. Pipe Insulation 100 e. Transite Shingles
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
f. Spray -On Fireproofing g. Transite Panels
1. Lin. FL 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
h. Cloths, Woven Fabrics i. Other - Please Specify:
1. Lin. Ft. 2. Sq. Ft.
j. Insulating Cement
1. Lin. Ft 2. Sq. Ft.
1. Lin, FL 2. Sq. Ft.
15. Describe the decontamination system(s) to be used:
THREECHAMBER
16. Describe the containerization/disposal 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)
18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this r a. Yes IV b. No
project?
Revised: 11/13/2013 Page 2 of 4
,C]
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
1100348134
Asbestos Project #
F Project Revision
f" Project Cancellation
1. Current or prior use of facility: RESIDENTIAL
2. is the facility owner -occupied residential with 4 units or less? W a. Yes lv In. No
MICHAEL BAILEY 244 WEST ST
3.
a. Facility Owner Name b. Address
MANSFIELD MA 02048 5083693806
c. City/Town d. State e. Zip Code f. Telephone
4. N/A N/A
a. Name of Facility Owners On -Site Manager b. Address
N/A MA 00000 0000000000
c. City/rown d. State e. Zip Code f. Telephone
S' N/A N/A
a. Name of General Contractor b. Address
N/A
c. Cityrrown
MA 00000 0000000000
d. State e. Zip Code f. Telephone
BEACON MUTUAL
g. Contractor's Workers Compensation Insurer
7296 8/25/2021
h. Policy # i. Expiration Date (MM/DD/YYYY)
6, What is the size of this facility?
1800 2
a. Square Feet b. # of Floors
C. Asbestos Transportation & Disposal
1. Transporter of asbestos -containing waste material from site of generation:
r a. Directly to Landfill or r. b. To Temporary Storage Location/Transfer Station
ASBESTOS CONTRACTOR
c. Name of Transporter
CRANSTON
e. City/Town
PO BOX 10417
d. Address
13 02910 4019464506
f. 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
YARDLEY
C. Lay/ I ow
301 OXFORD VALLEY RD
b. Address
PA 19067 8779999559
d. State e. Zip Code f. Telephone
Page 3 of 4
Massachusetts Department of Environmental Protection
1 BWP AQ 04 (ANF-001)
`;
Asbestos Notification Form
— —
�100348134
Asbestos Project #
T Project Revision
1° ProjectCaneellition
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 A 02895
8779999559
c. City/Town d. State e. Zip Code
f. 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. Citylrown e. State f. Zip Code
g. Telephone
Note: Contractor must
sign this form for DLS
notification purposes
A Certification
PETERGREIFFR
PEfERGREIFER
"I certify that I have personally 1. Name
2. Authorized Signature
examined the foregoing and am SUPERVISOR
6/21/2021
familiar with the information
contained in this document and 3. Position/Title
4. Date (MMIDD/YYYY)
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 R
02910
information is true, accurate, and
complete. I am aware that there 9. State
10. Zip Code
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
Page 4 of 4