HomeMy WebLinkAboutChauncy St. #75 - 3/25/2005Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
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Important:
When filling out
A. Asbestos Abatement Description�:e,
forms on the
computer, use
1. a. Is this facility fee exempt - city, town, district, municipal
housing authority, owner -occupied
only the tab key
residence of four units or less? [_e] Yes E/] No
to move your
—._. _
-------
cursor - do not
b. Provide blanket decal number if applicable:
-------------------------�
Blanket Decal Number
use the return
key.
2. Facility Location:
FORMER TWIST AND DRILL
75 CHAUNCY STREET
}
a. Name of Facility_ _ _
mansfleld — _ LMA _
b. Street Address
02048 ] (401) 728-6860
c. City/Town d State
e. Zip Code f. Telephone Number
INSTRUCTIONS
3. Worksite Location:
1. All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
THROUGHOUT
a. Building Name/Building Location b. Building # C. Wing d. Floor e. Room
Is the facility occupied? []Yes [✓] No
Asbestos Contractor:
AIR QUALITY EXPERTS INC 1
a. Name
SALEM !_ _� L03079 —�
c. City/Town d. Zi�Code
CC000167 _ �'
f. DOS License Number
6' GERMAN POSADA ZINIGA
a. Name of On -Site Supervisor/Fore
7 MATTJACQUEL
$' a. Name of Asbestos Analytical Lab
03/25/2005
o g' a. Project Start _Date mm/dd/yyyyL__ __LL_
0 7AM-4PM
a c. Work hours o M o-Fri—_. '_ _.-~
0 10. a. What type of project is this?
o Z Demolition ❑ Renovation
[] Repair [] Other, please specify:
11. a. Check abatement procedures:
o ❑ Glove bag
❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
LL ❑ Cleanup [_] Other, specify:
Z Full containment
Z
40 LOW ELL RD UNIT—
b. Address
6038946465
— — -- — e. Telephone Telephone�Number
g. Contract Type: [] Written ❑ Verbal
b. Describe
b. Describe
Q 12. Is the job being conducted: J✓] Indoors? ❑ Outdoors?
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
100014734
__.—_...,._..1
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
enca sulated:
0 L2000 fti
a. Total pipes or ducts ( near t) b. Total other su' ar`f ces square fti'
c. Boiler, breaching, duct, tank
E::
surface coatings
—A
Lin. ft.
e. Corrugated or layered paper
pipe insulation
Lin. ft.
g. Spray -on fireproofing
Lin. ft.
_
E---�
L Cloths, woven fabrics
Lin. ft.
_
k. Thermal, solid core pipe
L-1
insulation
Lin. ft.
14. Describe the decontamination system(s) to be used:
d. Insulating cement E--_1
Lin. ft.
f. Trowel/Sprayer coatings I--
Lin. ft.
h. Transite board, wall board `�—;-----I
I. Other, please specify:
43 WINDOWS
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
PLY WET POLY BAGS
16. For Emergency Asbestos Operations,
1500
the DEP and DOS officials who evaluated the emergency
d.. DEP Waiver #
f. DES OfRR Title
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 R] No
B. Facility Description
UFACTURING
1. Current or prior use of facility: MAN-----------------
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes [✓I No
DH HOLDINGS CORP 209SYW 1 9 PENNLVANIA AVE. N2T_H__FLOOR]
3' a. Facility Owner Name J (h. Address -
and
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Commonwealth of Massachusetts
1 3 IL
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
B.(FFaacility Description (cont.)
5.
a. Name of General Contractor
c,. Cityffown
f. Contractor's Workers Comp. Insurer T �_
6. What is the size of this facility?
100014734
Decal Number
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
AIR QUALITY EXPERTS, INC.
a. Name of Trans orter
� -�-_-�
c. City/Town
d. Zip Code
ILb. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
SERVICE TRANSPORT GROUP � CO BOX 2132
a. Name of Transporter.__
BRISTOL, PA — �19007 N�
Q
4. IA & L SALVAGE INC
111225 STATE ROUTE 45 1
e. State
D. Certification
�44432
I. 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.
LL
Z
a
anf001 ap.doc - 10102
FHRISTOPHER THOMPPS
a. Name
b. Authorized Signature_
03/07/2005 — —�
�_ _
PRESIDENT _�
c_Positionfritle
d. Date fmm/ddYyyyL___
LAIR QUALITY EXPERTS,
_
603 894-6465 _
e. Telephone Number
[40 LOWELL ROAD, UNIT ONE
g_Address
SALEM, NH
C3o79 _
h. City/Town
_l
i. Zip Code
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