HomeMy WebLinkAboutCentral St. #119 - 3/28/2007Commonwealth of Massachusetts
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Asbestos Notification Form ANF-001
Decal Number
FMAR
1 4 ?_0Impo07_
A. Asbestos Abatement Description
p
When filling a
When filling out
Toms to the
computer, use
1. a . Is this facility fee exempt- city, town, district, municipal housing authority,
owner-occuptied
only the lab key
residence of four units or less? I ✓� Yes �] No
to move your
cursor - do not
I-
b. Provide blanket decal number if applicable: Blanket Decal Number
-.:..
use the return
key.
2. Facility Location:
1119 CENTRAL ST.
a. Name of Facility b. Street Address
Mansfield jMA 020d8
-c. City/rown d. State e. Zip Code T. Telephone Number
INSTRUCTIONS 3. Worksite Location:
1.2ND FLOOR j Ill
form
All sections of this a. Building Name/Building Location b. Buildin # C. W� d. Floor e. Room form must be 9 9 9 9
completed in order
to comply with 4. Is the facility occupied? I0 Yes h No
DEP notification
requirements of 310
5 Asbestos Contractor
CMR 7.15
and the Division of Occupational
NEW ENGLAND SURFACE MAINTENANCE
Safety (DOS)
a. Name
notification
WEYMOUTH
requirements of 453
�c.
i02189
-Code.
CMR 6.12
City/Town d. Zip
AC000196
6 'JOHN S BUTTS JR
a. Name of On -Site Supsi
7. 'N/A
a. Name of Project Monitr
8N/A
.
a. Name of Asbestos Ana
9 !03/28/2007
a. Project Start Date Imr
j850 WASHINGTON STREET-
b. Address
I7813372117
e. Telephone Number
g. Contract Type
i. Contact Person's Tit
�ASO40209
b. Supervisor/Forema
jN/A
b. Protect Monitor DO
IN/A
b. Asbestos Analvlical
'03/28/2007__
b. End Date lmm/ddh
10. a. What type of project is this?
Demolition ❑ Renovation
Repair ❑ Other, please specify: b. Describe
11. a. Check abatement procedures:
✓' Glove bag
Enclosure
Cleanup
Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
b. Descnbe
12. Is the job being conducted: E/] Indoors? ❑ Outdoors?
0 anf001ap.doc - 10/02
Written ❑ Verbal
Asbestos Notification Form • Page 1 of 3
j Commonwealth of Massachusetts ■
Asbestos Notification Form ANF-001 Decal Number
0
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
to
I
a. Total pipes or ducts linear ft)
b. Iota]other
surfaces isquare
c. Boiler, breaching, duct, tank
7
��
7-1
surface coatings
ft.
Sq. ft.
d. Insulating cement
Lin. ft.
Sq. ft.
eCorrugated or laereda . gypaper
'uCLin.
I
L
I
_.
pipe insulation
Lin. ft.
Sq. ft.
f. Trowel/Sprayer coatings
Lin. ft.
Sq. ft.
I
i
g. Spray -on fireproofing
Lin. ft.
Sq. ft.
h. Trarsite board. wall board
Lin. ft.
sq. ft.
1. Cloths, woven fabrics
j. Other, please specify:
Lin. ft.
Sci. ft.
Lin. ft.
Sq. ft.
k. Thermal, solid core pipe
insulation
Lin. ft.
So
1. 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
IAS REQUIRED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
, I
a. Name of DEP Official b. Title
c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver #
� I
e. Name of DOS Official f. DOS Official Title
i I
g. Date (mmlddlyyyy) 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 Z No
B. Facility Description
RESIDENCE
1. Current or prior use of facility:
2. Is the facility owner -occupied residential with 4 units or less? [! Yes ll No
91
4.
■ anf001ap.doc - 10/02
Asbestos Notification Form • Pa a 2
C3
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
5' a. Name of General Contractor
I
c. Citv/Town it. ZiD Code
I. Contractor's Workers Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
■
100052633
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM LLP
a. Name of Transporter _
i
c. City/Town d. Zip Code
b. Address
I
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES
a. Name of Transporter b. Address
R
and
4. IMINERVA ENTERPRISES INC
9000 MINERVA ROAD
C. Final Disposal Site Address
OH 44688
e. State f. Zip Code
D. Certification
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.
212007
i
I. Zip Code
0 anf001ap.doc - 10102 Asbestos Notification Form • Page 3 of 3 0