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INSTRUCTIONS
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
H 0001
Decal Number
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? !_✓:, Yes ❑ No
b. Provide blanket decal number if applicable: Blanket Decal Number
2. Facility Location:
BILL DURGIN 25 COLUMBUS AVE.`
a Name of Facility b. Street Address
Mansfield !MA -02048
c. City/Town d. State e. Zip Code f. Telephone Number
3. Worksite Location:
!BASEMENT
1. All sections of this
form must be
a, Building Name/Building Location
b. Building #
completed in order
to comply with 4.
Is the facility occupied? ❑✓ Yes
No
DEP notification
requirements of 310
CMR 7.15 5.
Asbestos Contractor:
and the Division
of Occupational
NEW ENGLAND SURFACE MAINTENANCE
Safety (DOS)
a, Name
notification
requirements of 453
WEYMOUTH
j02189
CMR 6.12 -
c. Cityrrown
d. Zip Code
1. UUO ucenstl wun Nnr
6 JOHN S BUTTS JR
N/A...
7'
a. Name of Pr,
N/A
8.
As
a. Name of
0 9
j 10/29/2004
a. Project Sta
o
;8-4
a Work hours
N
C. Wing d. Floor e. Room
850 WASHINGTON STREET
b. Address
781-337-2117
e. Telephone Number
g. Contract Type: 7 Written _l Verbal
0 10. a. What type of project is this? _
o Demolition Fv_I Renovation
7 Repair ❑ Other, please specify: b. Describe
11. a. Check abatement procedures:
o ✓ Glove bag ❑ Encapsulation
o Enclosure ❑ Disposal only
Cleanup ❑ Other, specify:
Full containment b. Describe
z
4 12. Is the job being conducted: I✓l Indoors? ❑ Outdoors?
anf001 ap.doc • 10102 Asbestos Notification Form - Page 1 of 3
Commonwealth of Massachusetts ■
10 00100070 ' j
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:
i26 0
a. Total pipes or ducts (linear ft) 5. 1 otal other su aces square ft
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
i26
pipe insulation
Lin. ft.
g. Spray -on fireproofing
Lin. ft.
I. Cloths, woven fabrics Lin. ft.
k. Thermal, solid core pipe
insulation Lin. ft.
14. Describe the decontamination system(s) to be used:
IAS REQUIRED
d. Insulating cement �—
Lin. ft.
I. Trowel/Sprayer coatings Lin
h. Transits board, wail board
I. Other, please specify:
15. Describe the containerization/disposal methods to comply with 310 CMR 1.15 and 453 CMR
6.14(2) (g):
AS REQUIRED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name of DEP Official b. Title
i I
c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver #
i I
a. Name of DOS Official I. DOS Official Title
g. Date (mm/dd/yyyy) 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 0✓ No
B. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No
3.
4.
anf001 ap.doc • 10/02
Asbestos Notification Form • Pace 2�
LlCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
100010007 I
Decal Number
B. Facility Description (cont.)
I
5. a. Name of General Contractor b. Address
I
I
c. City/Town d. Zip Code e' Telephone Number area code and extension)
I I,
f. Contractor's Workers Comp. Insurer g. Policy Number h. Exp. Dates a (mm/dd/yyV
6. What is the size of this facility?
a. Square Feat � b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM
a. Name of Transporter b. Address
i i I i I
c. City/Town d. Zip Code e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
(WASTE MANAGEMENT
a. Name of Transporter
c. Cif/Town d. Zip Code
3. i
a. Refuse Transfer Station and Owner
i I
d. Zio Code
4. (TURNKEY LANDFILL (WASTE MGT
iL'i�ZN.IeYLl�[X�I:: a 9
e.
D. Certification
03839
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.
g. Address
i
h. Citylrown
b. Authorized Signature
I I
d. Date (mm/dd/yyw)
L I
i. Zip Code
IGo Tb Top
anf001 ap.doc • 10/02 Asbestos Notification Form - Page 3 of 3 N