HomeMy WebLinkAboutChauncy St. #75 - 4/11/2005Important:
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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
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Commonwealth of Massachusetts
1100015466
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description
a. Is this facility fee exempt city, town, district, municipal housing authority, owner occupied
residence of four units or less? (..:; Yes j,111 No
b. Provide blanket decal number if applicable:
2. Facility Location:
ER TWIST & DRILL
Mansfield 1 IMA
c. City/Town ..�,__..__._..�..,.._._ d. State
3. Worksite Location:
a. Building Name/Building Location lb. Building N
4. Is the facility occupied? [,.] Yes' ,,r No
5. Asbestos Contractor
AIR QUALITY EXPERTS INC
a. Name
1SALEM 03079
d Zip Code
_
AC000167
f. DOS License Number
_ . _. h
h. Facility Contact Person
IGERMAN POSADA ZINIGA
6
a. Name of On -Site supervisor/Foreman_
MATTJACQUEL
7.
a. Name of As
9. 04/11 /2005
7AM-4PM
c. Work hour.
10. a. What type of project is this?
✓j Demolition (., ! Renovation
L==] Repair U Other, please specify:
11. a. Check abatement procedures: .
11 Glove bag
f _ I Enclosure
L ) Cleanup
,✓j Full containment
LJ Encapsulation
L...) Disposal only
[ ` i Other, specify:
�. Blanket a nket Decal Number
b. Street Address
102048 (401) 728 6860
e. Zip Code I. Telephone Number
c. Wing d. Floor a.e. Room
_._..e..— ..._..,. ._._..., _.,_..,...
140 LOWELL RD UNIT-1
b. Address .............__._. _, .__ ,- -,�
16038946465
....._ ...... ....... _.__'
e. Telephone Number
g. Contract Type: [_] Written L i Verbal
I. Contact Person's Title
b. Describe
It. Describe
12. Is the job being conducted: i__l Indoors? i✓ Outdoors?
Go ToTop.
anf001ap.doc • 10/02 Asbestos NotiFlcation Form • Page 1 of 3
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
1100015466
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated
8000_..
a Total pipes or ducts (linear If) b. Total other surfaces (square ft)
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
_
1
pipe insulation
Lin, ft
'I
g. Spray -on fireproofing
! -
Lin. ft
i. Cloths, woven fabrics
F
I
'
Lin. ft.
k. Thermal, solid core pipe
T
j
insulation -.:
Lin: ft.:
-
d. Insulating cement
t
�
Lin ft
....-
Sq. ft
f. Trowel/Sprayer coatings
-
-j
Lin ft.
Sq ft
h. Transits board, wall board
Lin, R
�S ft.i
q
800
I. Other, please specify:
__._
Lm ft.,
( s
-
Sq. ft
WINDOWS_
L Specify��
14. Describe the decontamination system(s),to be used:
� —. . _._ _-.-
(/ E
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (Q):
PLY POL
16.
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
-_____ ----------- __ _-___
a. Name of DEP Official
b. TNe �'��� �'�' ' ���- _. -..". __i
c, Date (mm/dd/Yyyy) of Authorization --
..
�d DEP Waiver q -
e. Name of D-_- - -
OS Offlciai � I
I -' -
f DOS Official Title '
( mm/tld/ '....
g. Date yyyy) of Authorization �
h. DOS Waiver q
17.
Do prevailing wage rates as per'M,G.L. c. 149, § 26,
27 or 27A-F apply to this project? ; ) Yes j✓j No
B.
Facility Description
1.
Current or prior use of facility:MANUFACTURIONG
2.
Is the facility owner -occupied residential with 4 units
or less? 2,J Yes ✓i No
DH HOLDINGS
i2PE 099 NNSYLVANIE AVE NW 12TH FLOOR, l
3.
_....
a. Faalny Owner Name
IWASHINGTON20006
-
_ _... . _.. .. _.
b. Address
--
a City/Town .; d Zlp Code
e Telephone Number (area code and extension)
q
_ o
!a. Name f Fa_cillty Owner's _On -Site Manager
__ _(
(b On Site Manager Address
c. City/Town d. Zip Code
e. Telephone Number (area code and extension)
anf001ap.doc • 10102 Asbestos Notification Form • Page 2 of 3
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
L100015466
Decal Number
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
LAQE INC
a Name of Transporter
b. Address
a City/Town
d. Yip Code
'e. Telephone Number
2. Transporter of asbestos -containing waste material
from removal/temporary site to final disposal site:
!SERVICE TRANSPORT 111111GROUP
1PO BOX 2132 j
a. Name of Transporter __, !
BRISTOL 1
- - —
119007 k
b. Address
j(877) 999-9559
a City/Town .. ... _.__.,.
d Zip Code
. ,.
- - -
-a. Telephone Number
_.... l
a_. Refuse Transfer Station and Owner
_-
b. Addre.ss
a C�ty/Town_ _ _
4. A & L SALVAGE INC
d Zlp Code
a. Telephone Number _
}
a. Final Disposal Site Location Name
�11225 STATE ROUTE 45
�
b. Final Disposal Ste Locatiom n Owners Nae
�LISBON
rc,,Final Dispogal Sde Address
d. Oily/Town - -- {
LOH f
44432
e. State
f ZipCode
Nu g. Telephone Number
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.
anf001 ap.doc • 10/02
[CHRISTOPHER THOMPS
a. Name
PRESIDENT
b. Authorized Signature
0312812005
c. Position/Title _._
1(603) 894-6465 j
d. Date (mm/dd/yyyyl
1AIR QUALITY EXPERTS,
e.. Telephone N1. umber
f. Representing,
40 LOWELL RD UNIT 1
..._
._- ....._._ ........
q. Address _
_.._....__._ --
iSALEM .�- . .
' 079 7
03
h. CitylTown
i. Zip Code
Asbestos Notification Form • Page 3 of 3