HomeMy WebLinkAboutBrook St. #65 - 11/10/2003Commonwealth of Massachusetts
N---1111111 1100187410
L-11 Asbestos Notification Form ANF-001 Decal Number
Important:
A. Asbestos Abatement Description
When filling out
forms on the
1 a. Is this facility fee exempt city, town, district, municipal
m' p - �'
housing authority, owner -occupied
computer, use
only the tab key
residence of four units or less? 0 Yes ❑ No
to move your
cursor- do not
b. Provide blanket decal number if applicable:
Blanket Decal Number
use the return
kev.
2. FadifityLocation:
VC I
HUNT RESIDENCE
65 BROOK STREET
a. N;eaacili
TvlABLD —� Mgk
b. Street Address
JVMB i�38iy82S y4Sg
C. Cityfrovm d. State
e. Zip Code I. Telephone Number
INSTRUCTIONS
3. Worksite Location: (�
1. All sections of this HUNT RESIDENCE
town must be a. Building NamelBuildng Location b. Building # c. 4Mng d. Floor e. Room
completed in order
to coml%y vrith 4.
DEP notifiration
requirements m 310
CMR 7.15 5.
and the Division
M Occupa9oma3
Safety (DOS)
norraca0on
requirements of 453
CMRB-12
I-]
is the facility occupied? 0 Yes ❑ No
Asbestos Contractor.
MIDDLESEX INSULATION INC
HUNT
ITERRENCE ROBINSON I
7. a. Name of Pro ect Monitor
UNIVERSAL ENVIRONMENTAL CONSULTAN
8. _ .,_..... ..r n..r.e..n.� eeolulirnl 1 oh
4
V. YVuM nuM. IVIVIIYII.
10. a. What type of project is this?
❑ Demolition ❑ Renovation
R] Repair ❑ Other, please specify:
11. a. Check abatement procedures:
823 PLEASANT STREET
b. Address
7817699310
e. Telephone Number
g. Contract Type: ❑ Written ❑ Verbal
b. Describe
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only ❑ Cleanup Other, specify:
FULL REMOVAL OF TRANSITE BOARD
0
❑ Full containment b. Describe
12, Is the job being conducted: ❑ Indoors? 0 Outdoors?
E anf001ap.dw- 10102
Asbestos Notification Form • Page t of 3
IL7
Note: Transfer
Stations must
mmpiy wdh me
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
SOUTHERN MIDDLESEX INDUSTRIES, INC.
5' a. Name of General Contractor
NORWOOD—i 02062
c. C frown it Zi Code
FEDERAL INSURANCE CO.
f. Contractor's Workers Comp. Insurer
700767410
Decal Number
1822 PLEASSANT STREET I
-769-9310
6. What is the size of this facility? I
a. Square Feet b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
a Name ofTmns orter
O
c. Citylrown d. Zip Code
b. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removalltemporary site to final disposal site:
IRED TECHNOLOGIES LLG I
3.
4. IMINERVA ENTERPRISES INC
19000 MINERVA ROAD I
OH 44686
e. State f. Zip Code
D. Certification
The undersigned hereby states, under the
penalties of per)ury, that he/she has mad 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.
)OKE DAVIS
Me
AIN. ASSISTANT
sitioMlle _
)769-9310
lephooe Number
PLEASANT STREET
b. Authorized Signature
10/16/2013
d. Date mMdd!
SMI �—]
2. Address
NORWOOD -- — 102062
K City/Town L Zip Code
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0 anfg0lap.doc • 10102 Asbestos Notification Form • Page 3 of 3
Commonwealth of Massachusetts
,t
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
f00187410
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
,enc�a s-ulat—ed:—
�0 28
'—a o1a1 pipes nr duds (fineas ) SToaaMaT su ces kzware
c. Boiler, breaching, duct tank
= = d. Insulating cement
O
surface coafings
layered
Lin. ft. Sq. fi.
=
Lin. ft.
e. Canugated or paper
pipe insulation
f. Trowat Sprayercoatings
Lin. fl. Sq_ ft.
ft.
1
(Lin.
g. Spray -an fireproofing
Lin. Sq. h. Transite board, wall board
Lia ft.
j. Other, specify.Lin
i. Cloths, woven fabrics
Please
Lin S
,L�
k. Thermal, solid core pipe
I I
Insulation
Lin. tL Sq. ft. I. Specify
14. Describe the decontamination system(s) to be used:
APPROPRIATE DECON SYSTEM PRESCRIBED BY DLI WILL BE USED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
JALL ACM WILL BE WET AND DOUBLE BAGGED IN 6MIL LABELED BAGS
16. For Emergency Asbestos Operations, the DEP and DOS offmiais who evakuated the emergency
a. Name of DEP0 as b. Tithe
c. Date (mm/ddfyyyy) OfALM0nzation d. DEP Waiver#
e. Name of DOS Official T. UVb kJMCh1l I Itle
n�tP rmmmd/wvvl 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 0✓ No
B. Facility Description
1. Current or prior use of taclTiiy:
RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? 0 Yes ❑ No
3.
4.
0 ard00tap.doc • 10102
65 BROOK STREET
b. Address
781-821-1469
e. Tele hone Number (area code and extension)
WA
b. On -Site Manager Address
e. Telephone Number (area code and extension)
Asbestos Notification Form • Papa 2 of 3