HomeMy WebLinkAboutCentral St. #255 - 2/16/2011FEB-15-2011 12:22 FROM: TO:15082617343 P.2
Commonwealth of Massachusetts ■
0
100120073
Asbestos Notification Form ANF-001 °°`°'"am°°'
penanb
A. Asbestos Abatement Description
WSlllnq out
P
forWhen
011 the
come
computer, vas
1.
a. is this facility fee exempt, a town, district, municipal housing authors owner•owu led
tY P city, Pa 9 authority, P
only the tab key
residence of four units or less? ✓ Yes No
to move your
WrOor- do not
b. Provide blanket decal number if applicable:
,.
Blanket Decal Number —
ueethe return
key.
2.
Facility Location:
ss
a
r
ANTHONY JODICE
263 CENTRALST
a. Nome of Facility
b. Street Address : J
a
MANSFIELD MA
02048 (508) 60,446
c. Cityn'own d. state
9. Zip Coda
INSTRUCTIONS
3.
Worksite Location:
t.rdlaeouonsormia
SAME
torn must be
a. Building Nameraullding Location b. eulming s
C. wing (. Flocr e. Room
completed In order
to CCmply with
4.
IS the facility Occupied? ✓ Yes No
OUP notification
of 310
CMR Ym5n1a
5.
Asbestos Contractor.
and the pwlon
olD"ouloonal
AIR SAFE INC
$story (008)
it. Name
um m
requilremev nt 0r463
NORWOOD
CMR e.t2
GCIIyRawn �
AC000464
f. DOS License Number
61 ENDICOTT STREET
b. Address
02062 7817623390
d. Zip Code 0. Telephone Number
h. Facility Contact Person
6 JAIME E AMAYA
a. Nome of On -Site Supervisormoremon
T NA
R. Name of Project Monitor
6. NA
a, Name of Asbestos Anatyticul Lab
9 02l76f2011
e. Project Start Data (mmiddryyyy)
7AM - 6PM
C. Work hours Mon-ft
10, a. What type of project is this?
Demolition Renovation
Repair Other, please specify,
11. a. Check abatement procedures:
✓ Glove beg Encapsulation
Enclosure Disposal only
Cleanup Other, specify
Full containment
12. Is the job being conducted: ✓ Indoors?
0 an1001ap.doc• 10f02
g. Contract Type: ✓ Written Verbal
1. Contact Pareon's Title
A6060847
b, Supervlsorrfrommen DOS Certification Number
b. Project Monitor DOS Certification Number
b, Asbestos Anahrtical LabDOS Certification Number
02 I012011
b. Brd Pat* fmmtsdNW)
4. Work hours Sat -Sun.
b. Descaba
Outdoors? �J
Asbestos Notification Form . Page 1 of 3
FEB-15-2011 12:22 FROM: TO:15082617343 P.3
Commonwealth of Massachusetts ■
100120073
0 Asbestos Notification Form ANF-001 Oecal Number
A. Asbestos Abatement Description (cant.)
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
190 0
e. Total pipes or nude (rnear ft) b. Total other sudacee(squam ft)
c. eoller, breaching, duct, tank d. Insulating cement
surface coatings Lin. ft. Sq. ft. Lin. ft sq. ft.
a. Corrugated or layered paper 190
pipe insulation Lm, ft Sq, ft. f. TroweuSpmyer wadnps Lin. IL sq. ft.
g. Spray.on frepreofing Lin. ft. Sq. ft.
I. Cloths, woven fabrics Lin. ft. Sq. ft.
k. Thermal, solid core pipe
Insulapon Lin. ft. sq. ft.
14. Describe the decontamination systems) to be used:
3 CHAMBER DECON
h. Transfte board, wall hoard tan. n 5q• ft.
I.Other, please specify;
Lin. R. Sq. a.
L specify
IS. Describe the containerization/disposal methods to comply with 310 CMR 7.16 and 463 CMR
8.14(2) (9):
8 MIL POLY BAGS
16, For Emergency Asbestos Operations, the DER and DOS Officials who evaluated the emergency:
a. Name of DEP Official b. Yee
c. Data (mm/ddlyyyy) of Aulhorizatiun d. IMP Waher i
e. Name of 003 Otdclat I. DOS official Title
9. Date (mmlddlyyyy) orputhodzallon h. DOS Waivers
17, Do prevailing wage rates as per M.G.L. C. 149, § 26, 27 or 27A—F apply to this project? Yes ✓ No
S. Facility Description
1. Current or prior use of facility: RSIDENTIAL
2. Is the facility owner -occupied residential with 4 units or less? ✓ Yes No
3. SAME
a. Fardllly Owner Name b. Address
o. Cilyftown d. Zip Code e. Telephone Number (am@ code and extension)
4. a. Name of Fecilfty Owneft On�Slte Manager b. On -She Manager Address
o. City/rown
0 anroolap.doc-low
d. Zip Code e. Telephone Number (area code and extension)
Asbestos Notification Form • Page 2 of3.�
FEe-15-2011 12:22 FROM: TO:15082617343 P.4
Commonwealth of Massachusetts0
■
1001121111073
Asbestos Notification Farm ANF-401 Decal Number
Note: Transfer
Stations must
comply with the
Solid Waste
Olvlelon
Regulations 310
CMR 19.000
B. Facility Description (cont.)
5. a. Name of General Contractor
c. Cityfrown
I. conmoctoes vyorkols Comp, Insurer
6. What is the size of this facility.)
b. Address
e. ZIP Code a. Telephone Numbs (area code and f aerulan)
g. Policy Number h. UP. Data (mm14dryyyy)
a. Square Feet b. Number of floors
1. Transporter of asbestos -containing material from aite to temporary storage site (if necessary):
AIRSAFE
a. Name of Transporter
b. Address
C. Clryrrown d. Zip Cade a. Telephone Number
2. Transporter of asbestos-contalning waste material from removal/temporary site to final disposal alto:
Kl
a. Name of Treneponsr
a Cltyfrown d. ZIP Code
a. Refuse Transfer Station and Owner
o. C4frown d. 21P Code
4, 1 NO REMOVAL.. DISTURBING ONLY DHCDd
a. Final Disposal She Location Nome
NO REMOVAL. DISTURBING
d. Final Dlsbosat Site Address
MA 02108
a. State f. zip Code
b. Address
e. Tolephanp Number
b. Address
e. Telephone Number
b. Final Disposal she Location ournees Name
BOSTON
d. Cbfrown
g. Telephone Number
D. Certification
The undersigned hereby states, under the
DF WALSH ,
penaltieb of perjury, that he/she has read the
a. Name
b. Authorized signature
Commonwealth of Mosaochusatts regulations
VP
for the Removal, Containment or
Encapeulation of Asbestca, 453 CMR 6.00 end
,
C. PosmaMl'lue
d. Date (mmlddryWY)
31.0 CMR 7.16, and'that the information
(781 ) 76 23390
AS
contained in this notificagon is true and Correct
0. Telephone Number
f. Representing
to the best of his/her knowledge and belief,
61 ENDICOTT
r
g. Address
NORWOOD
02062
h. Cltyrrown
1. Zip Code
■ anfoofap.doc• tom
Asbestos Notifloation Fomh'• Page 3 of 3 �