HomeMy WebLinkAboutBicentennial Ct. #22 apt. 12 B - 11/20/2018Instructions 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
Date Received
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
A. Asbestos Abatement Description
1. Facility Location:
MANSFIELD HOUSING AUTHORITY
a. Name of Facility
MANSFIELD
c. City/Town
ANDREAMCDOUGALL
g. Facility Contact Person Name
Worksite Location:
2. Is the facility occupied? fv- a. Yes f' b. No
�100298549
Asbestos Project #
F Project Revision
r Project Cancellation
22 BICENTENNIAL COURT UNIT 12B
b. Street Address
NIA 02048 5083396890
d. State e. Zip Code f. Telephone
DIRECTOR
h. Facility Contact Person Title
UNIT 12 B CEILINGS THROUGHOUT
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)? r a. Yes r b. No
4. Blanket Permit Project Approval, if applicable:
Approval ID #
5. Non -Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID #
6. Asbestos Contractor:
AIR SAFE INC
a. Name
22 WILLOW STREET
b. Address
CHELSEA MA 02150 9783395361
c. City/Town d. State e. Zip Code f. Telephone
AC000464 h. Cont-act Type: r 1. Written f 2. Verbal
g. DLS License #
7. JAIME EAMAYA AS060847
a. Name of Contractor's On -Site Supervisor/Foreman b. DLS Certification #
$ KEVIN CLIFFORD
a. Name of Project Monitor
AM000092
b. OILS Certification #
9. FUENVIRONMENTAL INC AA000144
a. Name of Asbestos Analytical Lab b. DLS Certification If
10.
11/19/2018 11/20/2018
a. Project Start Date (MM/DD/YYYY) b. End Date (MM/DD/YYYY)
7AM-5PM NA
c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday
11. What type of project is this?
r a. Demolition W, b. Renovation r— c. Repair r d. Other - Please Specify:
Revised: 11/13/2013
Massachusetts Department of Environmental Protection
1100298549
-'40�,' _. BWP AQ 04 (ANF-001) Asbestos Project a
?'` Asbestos Notification Form
r Project Revision
�l
F Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
f a. Glove Bag f- b. Encapsulation r c. Enclosure f d. Disposal Only r c. Cleanup
r f. Full Containment r g. Other - Please Specify:
13. Job is being conducted: r a. Indoors f b. Outdoors
14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
500
1. Linear Feet (Lin. Ft.) 2. Square Feet (Sq. 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.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. FL 2. Sq. Ft.
15. Describe the decontamination system(s) to be used:
THREE CHAMBER DECON
c. Transite Pipe
e. Transite Shingles
g. Transite Panels
i. Other - Please Specify:
TEXTURED S11M COAT
1. Lin, Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
500
1. Lin. Ft. 2. Sq. Ft.
16, Describe the containerization/disposal methods to comply with 310 CMR 7,15 and 453 CMR 6.14(2)
(g):
6 MIL POLY
17, For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:
COLLEEN MCCONNELL
ASBESTOS INSPECTOR
a. Name of MassDEP Official
b. Title of MassDEP Official
11/16/2018
SAW 18-509
c. Date of Authorization (MM/DD/YYYY)
d. Waiver#
SYSTEM
ASBESTOS INSPECTOR
e. Name of DLS Official I. Title of DLS Official
11/16/2018 24208-2018
9. 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 f- b. No
project?
Page 2 of 4
Massachusetts Department of Enviroumental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
B. Facility Description
1. Current or prior use of facility:
RESIDENTIAL
1100298549
Asbestos Project it
r Project Revision
r Project Cancellation
2. Is the facility owner -occupied residential with 4 units or less? r a. Yes W b. No
3 MANSFIELD HOUSING AUTHORITY 22 BICENTENNIAL CT UNIT
a. Facility Owner Name b. Address
MANSFIELD
a City/Town
ANDREA MCDOUGALL
a. Name of Facility Owners On -Site Manager
NIA 02048 5083396890
d. State e. Zip Code f, Telephone
22 BICENTENNIAL CT UNIT
b. Address
MANSFIELD MA 02048 5083396890
c. Cilyrrown d. Slate e. Zip Code f. Telephone
5'NA NA
a. Name of General Contractor b. Address
NA MA 02048 5083396890
c. City/Town d. Stale e. Zip Code f. Telephone
NA
g. Contractors Worker's Compensation Insurer
NA 12/31/2018
In. Policy # I. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility? 500 1
a. Square Feet b. # of Floors
Note: Temporary storage of Asbestos C. Asbestos Transportation & Disposal
containing waste
1. Transporter of asbestos -containing waste material from site of generation:
material is only
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
AIR SAFE INC
22 WILLOW ST
station that is
c. Name of Transporter
d. Address
permitted by
MassDEP and
CHELSEA
MA 02160 9783395361
operated in
e. CitylTown
f. State g. Zip Code It. 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 fi,on1 temporary storage location/transfer station to final disposal site:
SERVICE TRANS GROUP
301 OXFORD VALLEY RD STE 803E
a. Name of Transporter
b. Address
YARDLEY
PA 19067 8779999559
c. CityfTown
d. State e. Zip Code f. Telephone
13 Page 3 of 4
\_
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j
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
100298549
Asbestos Project u
n
f Project Revision
r Project Cancellation
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos
containing waste
material:
AIR SAFE INC 22 WILLOW ST
a. Temporary Storage Location Name b. Address
CHELSEA MA 02150 9783395361
c. Cily7Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA ENTERPRISES, INC
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8995 MINERVA DRIVE
c. Address
WAYNESBURG OH 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."
1. Name
PRESIDENT
3. Position/Tille
9783395361
5. Telephone
23 WYCHWOOD DR
7. Address
MA
9. Slate
2. Authorized Signature
4. Date (MM/DD/YYYY)
AIR SAFE INC
6. Representing
UTTLETON
8. CityfTown
01460
10. Zip Code
Revised: 11/13/2013 Page 4 of 4