HomeMy WebLinkAboutBalcom St. #40 - 8/15/2007Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
■
100059176
Decal Number
1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? ❑ Yes 2:1 No
b. Provide blanket decal number if applicable: Blanket Decal Number
2. Facility Location
IHOCKOMOCK YMCA
1 140 BALCOM STREET
Name of Facility
b. Street Address
,a.
Mansfield
IMA 102048
c. City/Town
d. State e. Zip Code f. Telephone Number
3. Worksite Location:
1. All sections of this i BOILER ROOM
forth must be a. Building Name/Building Location
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
b. Building # c. Wing d. Floor e. Room
Is the facility occupied? F/ Yes ❑ No
Asbestos Contractor:
'NEW ENGLAND SURFACE MAINTENANCE
IAC000196
f. DOS License Number
h. Facility Contact Person
6 !JOHN P VALLIQUETTE
a. Name of On -Site Supervisor/Foreman
7 �JERRY LEBLANC
0
9.
o
,BAN
89
ENVIROTEST LABORATORY I
0 10. a. What type of project is this?
0
11.
0
0
LL
Z
❑ Demolition ❑✓ Renovation
❑ Repair ❑ Other, please specify:
a. Check abatement procedures:
F Glove bag
Enclosure
r. Cleanup
7 Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
00 WASHINGTON STREET j
b. Address
17813372117
a. Telephone Number
g. Contract Type: ❑ Written ❑ Verbal
j
b. Describe
b. Describe
ml�<
12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
■ anf001 ap.doc • 10/02
0 99�oT�
AUG 0 2 2007
Asbestos Notification Form • Page 1 of 3 ■
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
0
■
100059176
Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
60 I
160
a. pipes or ducts (linear )
6. 1 c a o er su aces square
c. Boiler, breaching, duct, tank
60
surface coatings
d. Insulating cement
Lin. ft. Sq. ft.
Lin. ft. Sq. ft.
e. Corrugated or layered paper
-60
f. TrowellSprayer coatings
i
pipe insulationII
Lin. ft. Sq. ft.
Lin. ft. Sq. ft.
I
g. Spray -on fireproofing
Lin. ft. Sq 1 h. Transite board, wall board
u�
Lin. ft. S
'= F
I. Cloths, woven fabrics
I. Other, please specify:
Lin S�
Lin. ft. Sq. ft.
k. Thermal, solid con: pipe
insulation
Lin. ft. Sq. ft. I. Specify
14. Describe the decontamination
system(s) to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
16. For Emergency Asbestos Operations, the DPP and DOS officials who evaluated the emergency:
a. Name of D P fficial b. Title
c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver #
e, Name of DOS Official f. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization 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: YMCA
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No
3.
4.
■ anf001 ap.doc • 10/02
Asbestos Notification Form - Pairs 2
LCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
B. Facility Description (cont.)
5. a. Name of General Contractor
i
c. Cit crown d. Zi Cade
I. Contractor's Workers Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
100059176
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM, LLP
'a. Name of Transans ode
c. City/rown d. Zip Code
b. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
9
4. IMINERVA ENTERPRISES INC
9000 MINERVA ROAD I
e. State
D. Certification
d. City/Town
44688
I. Zip Code g. Telephone Number
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.
9. Address
h. Cilyfrown i. Zip Code
ant001 ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3
0 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Important:
When filling out
forms on the
computer, u$e
only the tab key
to move your
rt cuor - do not
use the return
key.
.... 10000127s
Decal Number. ,,.._., ,.
Affix Asbestos
Notification Decal
Here
A. Asbestos Abatement Description
1. a. is this facility fee exempt - city,, town, district, municipal housing authority. owneromupled
residence of four units or less? - Yes ✓ No
b, Provide blanket decal number if applicable: gianketoecal Number
2. Facility Location:
YMCA
a. Name of Facility ....
MANSFIELD 'MA
d. state
3 Worksite Location:
40 BALCOLM ST -
.... ;. br SiLgal Address .
02045
TetePhone Number
INSTRUCTIONS
SAME
1. AN Sectors of this
form must be
a. Building Name/Building Location
b. Building 4
completed In order
to comply with 4.
is the facility occupied? '✓ Yes
No
UP notification
menu ofato
5.
Asbestos COntmCt0r:,
CMR TIS
CMR L,,
,_- ...
and the olvieion
AIRSAFE INC
of omvpadonel
... ...
.. . -_
Safety (DOB)-
notirkallon
.02062
regulromente of 453
,NORWOOD - . . I .
_....... ...
G.
'
'A. ZIP code
CMR6.12
. . qT! ... ... ........
_.
AC000464
_......., ..........
t, DOS'Cicenee•"Nu�ribei .'_._ ' .... ..,.
.. ...
'c;'wing d. Floor e. Room
■
. ... ..._ _ .
:61 ENDICOTT ST SLOG 92
b. Address .... ..... ... ... ......... ..... ...
7011623390
....._ .......4... _ ..
a, Telephone Number
g. Contract Type: Written . Verbal
. ..
h, Kacifliy contact i Neon ... ...... .....
1, COMiNt P�rsoe a Title ..... .. ......... . ... _ ....._....
5,
JAIMEE.AMAYA
-' •' ' '
e, Nema of OnSke, SepeMewlFo!eman,•, . , .
.AS050047. _,,,_, • , _ _ ...,....
b. S erviaar�Fmwnen DOS ceAlAcation Namliar .,.
.. �.. ..
T,
NIA_:
.. ......
e._Wma e1 Project Moeka._._............... . ._.. _ _ ...
........ .............._..._ .
b. vmjeel Mooltor DOS Car1MIP�ilai, u..._. .,,.--... ... _.....
_. _
8•
.a. Name of gs"jgi .._. m.Iyt-.I l.ab.„. ......... .... ...'
ld ?•�....
.�, Aabsgl _Aaa!vljt+itl.eb DOS yrIMrAtipri,Ngm f._... _
10� 2ooa ..__.__...... i
,ti197i2003 .-
_C„��.........
9.
7:00-5:00 .. ..........._... .._....._.
a. Wok taus Mor�Fl.•...
_.._.... _._...._...I
d.WorkiioilRSaFSun.
10.
a. What type of project IS this?
.._...._,._............. . ._ -_.._.
Demolition Renovation
Repair a Other, please speCUy:
b. Describe
11.
a. Check abatement procedures:
Glove bag ;neapsulation
'Enclosure _..: Disposal only
, .... _. ._........._...._ .... ..�..__.....,.
Cleanup i.. Other, specify:
Full containment
b. Describe
12.
Is the job being conducted: ice; Indoors? ....: Outdoors?
0 anf001 mp,doc • 10102
Asbestos Iff ifficatlon Form' Page 1 of 3 N
AirSafe, Inc.
4KALCK-IDT 7
DATE: /iO//°�.v
NUMBER OF PAGES (INCLUDING COVER SHEET): 4
TO: TOWN OF MANSFIELD - BOARD OF HEALTH
FAX RECEIVING #: 508-261-7343
FAX SENDING #: 781-762-2815
61 Endicott Street, Bldg. 32-1
funVW4 MA WOW - MI-762-3390
The Experts /n Asbestos Removal