HomeMy WebLinkAboutCentral St. #375 - 2/5/2004FL
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INSTRUCTIONS
1. All sections of this
form must be
completed in order
to comply with
DEP notification
requirements of 310
CMR 7.15
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
Commonwealth of Massachusetts ■
100002482
Asbestos Notification Form ANF-001 ----Decal Number
Affix Asbestos
Notification Decal
Here
-----------------
A. Asbestos Abatement Description
1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? Z Yes ❑ No
b. Provide blanket decal number, if applicable:
Blanket Decal Number
2. Facility Location:
DAWN FOLEY
;375 CENTRAL ST
_
a. Name of Facility b. Street Address
Mansfield 102048 1 1(508) 337-5989��
c. Cityrrown d. State
e. Zip Code f. Telephone Number
3. Worksite Location:
BASEMENT
��
L � C= C=
a. Building Name/Building Location b. Building #
C. Wing d. Floor e. Room
4. Is the facility occupied? Z Yes ❑ No
5. Asbestos Contractor:
DUDLEY SERVICES, INC.
43 DUDLEY STREET, PO BOX 132
a. Name b. Address
ARLINGTON 02176 1 17816434328
c. City[Town d. ZipCode a
e. Telephone Number
AC000112
I. DOS License umber
Contract Type: �✓ Written El Verbal
h. Facility contact Person_
6 �SAMUEL J. NIGRO
Igo.
i. Contact Person's Title
AS032802
a. Name of On -Site supervisor/Foreman
ENVIROSAFE ENGINEERING
b. Su ervisor/Foreman DOS Certification Number
JAM060297
7
a. Name of Project Monitor
ENVIROSAFE ENGINEERING
b. Project Monitor DOS Certification Number _
AA000131
8
^^^ ^
g' a
TO 5PM
10. a. What type of project is this?
[ Demolition ❑✓ Renovation
Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
El Enclosure
❑ Cleanup
[✓j Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
b. Describe
b. Describe
12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
0 anf001ap.doc • 10102 Asbestos Notification Form • Page 1 of 3 0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
t
A. Asbestos Abatement Description (cont.)
■
100002482
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
50ca sulated: �"I
a. Tota pipes or ucts linearr ft) 6-'fo aal other surTaces (squarefij
c. Boiler, breaching, duct, tank
36
surface coatings
Lin. ft.
Sq. ft.
e. Corrugated or layered paper
50
pipe insulation
ft.
Sq. ft.
(Lin.
g. Spray -on fireproofing
iL'n ft
S�
i. Cloths, woven fabrics
i�
�.J,I
k. Thermal, solid core pipe
insulation
Lin. ft.
Sq. ft.
d. Insulating cement
ft
�Lin.
(I�
f. Trowel/Sprayer coatings
Lin _J
h. Transite board, wall board
Li��
I. Other, please specify:
iu
14. Describe the decontamination system(s) to be used:
CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
WETASBESTOS PACKED IN DOUBLE 6 MIL. POLY BAGS LABELED ASBESTOS
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency
a. Name or ut_v vmciai b. Title
Da (mmlddl yy) of Authorization d. DEP Waiver #
((a�.. ``N�aam�ee of DOS Official . D icial Tit e
_
g. Date (mmldd/yyyyj 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: RESIDENTIAL DWELLING
2. Is the facility owner -occupied residential with 4 units or less? Z Yes ❑ No
3.
9
■ an1001 ap.doc - 10/02
Asbestos Notification Form • Pa a 2
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
5' a. Namea Name of —General ractor
a Ci /Town d. Zi Cp ode
f. ContractoYs Worker's Comp. Insurer ��"�.1
6. What is the size of this facility?
U. Asbestos Transportation and Disposal
1000024 22
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary)
Note: Transfer a. Name of Transporter b. Address
Stations must E==_
comply with the c. City/Town d. Zip Code e. Telephone Number
Solid Waste
Division 2. Transporter of asbestos -containing waste material from removal/temporary ora site to final disposal site:
Regulations 310 9 p fy p
CMR 19.000 JOB ROLLOFF
3.
Co
NH_
e. S
NECK
D. Certification
50
E
f. Zip Code
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.
anf001 ap.doc • 10/02
DLEY
43 UDLEY ST.
g. Address
ARLINGTON, MA OF2476 1
h. City/Town i. Zip Code
Asbestos Notification Form • Page 3 of 3