HomeMy WebLinkAboutChauncy St. #75 - 2/21/2005Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
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
0
0
N
0
0
0
0
LL
Z
Q
Commonwealth of Massachusetts ®I
100013041
Asbestos Notification Form ANF-001 Decal Number
FIJACN
A. Asbestos Abatement Description
a. Is this facility fee exempt - city, town, district, municipal housing authority,
racidP.nna of fro Ir Itnitc nr lace') i -i Vac : Nn
b. Provide blanket decal number if applicable:
2. Facility Location:
IFORMER TWIST AND DRILL
a, Name of Fac
lI _dity _
;Mansfield MA
_
c. City(Town _ d State
3. Worksite Location:
jTHROUGHOUT_
a. Building Name/Building Location b. Building N
4. Is the facility occupied? [ e Yes i'✓j No
5. Asbestos Contractor:
iAIR QUALITY EXPERTS INC
a. Name _ ,-,
(SALEM03079
6 IGERMAN POSADA ZINIGA
7 (MATTJACQUEL
[7
70
10. a. What type of project is this?
✓J Demolition iLL. Renovation
j_mj Repair i__j Other, please specify:
11. a. Check abatement procedures:
( I Glove bag I .,i Encapsulation
-i Enclosure j -j Disposal only
[,,,I Cleanup 1 Other, specify
(✓J Full containment
Blanket Decal Number
,75 CHAUNCY ST
w _. _..... .. . ...... ...
b. Street Address _
M048 ?(401) 728-6860
e. Zip Cade f. Telephone Number
c. Wing d. Floor e. Room
40 LOWELL RD UNIT 1
--_
b. Address
6038946465
e. Telephone Number
g. Contract Type: [✓j Written 1 1 Verbal
b. Describe
... ........ _... T _......._ ._
b. Describe
12. Is the job being conducted: [ Indoors? l !1 Outdoors?
Go7o.Top'.
anf001 ap.doc • 10102 Asbestos Notification Form • Page 1 of 3 0
ILI
Commonwealth of Massachusetts ...., _-.._._., .. .,..., �i
1100013041
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13.
Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated
p088 9843
_ _.
a Totai pipes or ducts (Imear k) b. Total other surfaces (square k)
d
c. Boiler, breaching, duct, tank [ (430 i I I t
-- -- d. Insulating cement
surface coatings Lin. ft Sq. ft Lin, Sq ft.
-
1750 I f. ( ..... .3
e. Corrugated or layered paper ( r Trowel/Sprayer coatings
pipe insulation Lin. ft Sq. ft. Lin ft. j Sq. ft.
g. Spray -on fireproofing --- J - -i h. Transite board, wall board
Lin. ft Sq. it Lin ft. Sq ft.
_m
l
I 17338 I i9413
I. Cloths, woven fabrics Other, leases specify: -.l
Lln..-ft S , ft y
q,. 9
E i GLU TIL CLK D
k. Thermal, solid core pipe L I ( r _,1
- -
-
Insulation Lin. ft. Sq. ft. I. Specify
14.
Describe the decontamination system(s) to be used:
3 CHAMBER DECON E
15.
Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
j2 PLY WET POLYBAG
16.
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name of DEP Official " " b. Title T"W""
w_. _ ....... ...' ___ .. _. __. ...
c. Date (mm/dd/yyyy) of Authonzation d DEP Waiver q
..e..
e. Name of DOS Official i. DOS Official Title
r
N
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver N
0 17.
Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A-F apply to this project? (; Yes ✓i No
B.
Facility Description
MANUFACTURING
0 1.
Current or prior use of facility:
0
2.
Is the facility owner -occupied residential with 4 units or less? Li Yes (✓( No
3.
tDH HOLDINGS CORP 12099 PENNSYLVANIA AVE NW 12TH FLOOR!
_ _ .------ __ __._ .._... __ _ ... _ _ __ _
a. Facility Owner Name b. Address
0
WASHINGTON (20006
L._. ._._ ._.._ ._.. L
o
c/Town d Zip Code e Telephone Number (area code and extension)
4-.
_ .. .. ._
a- Name of Facility Owners On Site Manager b On site Manager Address
__ .
Q
cJCity/Town d. Zip Code e. Telephone Number (area code and extension)
anf001 ap.doc • 10/02
Asbestos Notification Form • Pace 2 of 3
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 ofGeneralContractor
I . . I
C. _. tl Zip Code
F'Lft
1 f. corvra c-tor-'s _Wo'rker'a com p-. "Insuie r,
6. What is the size of this facility?
b. Address
,M0013041
6—eca-1 Number_
a.Telephone
1.p....... . Number
-er�. (area code and extension)
xt"ension)
F —---
..
I
I
9. P0l!9y_Nmpqer ....... . .... ...... bKxpDate kTm/dc1yyy,y)
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):
SAQE INC
.a.,Nameomansporter
c. City/Town d. Zip Code
th. Address_.
--- -- -----
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
j§ERVICE TRANSPORT GROUP TO BOX 2132 - -
a. Name of TraRspmrtqr_ b. Address
.......... .
... ....
JBRISTOL ... 7__ - - I
1(i ... 7-7,)--9,99-9559
43
a. Refuse
4. 1A&LSALVAGE INC
11225 STATE ROUTE 45
- Final Disposal S-Re-Address
OH
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.
g. Telephone Number
[C-H'RiifaPHER i_—HO'MPSt
a arne,
l.N
jPRESIDENT
b. Aulhorlzed, Signature_
2005
011_111V'� ...
,c,posidon/.Tiflo
894-6465
d. Date (mmIdd VVVy)
JAIR
(603)
- ----- ------
QUALITY EXPERTS, I'
I I I
r a. Telephone Number
rRepresenting
140 LOWELL RD UNIT I
Address
,q,.,
SALEM 1
030179.1 111
b. City/Town-
1. Zip Code
Go �To
0 anf001 ap.doc - 10/02 Asbestos Notification Form - Page 3 of 3 0