HomeMy WebLinkAboutEast St. #240 - 12/23/2011Important:
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INSTRUCTIONS
1. All sections of this
for 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
100139647
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? E/] Yes F] No
b. Provide blanket decal number if applicable:
Blanket Decal Number
2. Facility Location
QUALTERS MIDDLE SCHOOL 240 EAST STREET
a. Name of Facility _ _ b. Street Address11
(Mansfield _ ._..._� �MA 02048 v _._�
c. Citylrown d. State e. Zip Code f. Telephone Number
3. Worksite Location:
SPEECH OFFICE
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
4. Is the facility occupied? J✓l Yes (] No
5. Asbestos Contractor:
(INEW ENGLAND SURFACE MAINTENANCE
a. Name W__ _
EYMOUTH �Fa CO2189
c. CitylTown _ _ d Zip Code
�AC000196
f. DOS License Number
LPAUL W. BRO'
6' a. Name of On -Site
OWNERS REP
7' a. Name of Project
OWNERS REP
8. a. Name of Asbestc
9. 12/23/2011
a. Project Start Da
112-8
10. a. What type of project is this?
El Demolition El Renovation
0 Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
El Enclosure
❑ Cleanup
n Full containment
❑ Encapsulation
Disposal only
Other, specify:
850 WASHINGTON STREET i _
b. Address
7813372117
e. Telephone Number
g. Contract Type: 0 Written F.1 Verbal
b. Describe
b. Describe
12. Is the job being conducted: (✓J Indoors? ❑ Outdoors?
anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 0
LJCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
■
100139647
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
a� pipes or ducts (linear ft) b. T`o1her sillkes�(square�
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
I_ ___ I
pipe insulation
Lin. ft.
g. Spray -on fireproofing
.----__---
Lin. ft.___..
I. Cloths, woven fabrics
--- ---I
Lin. ft.
k. Thermal, solid core pipe
insulation
_-}
Lin. ft.
14. Describe the decontamination system(s) to be used:
AS REQUIRED
d. Insulating cement-----�
Lin.
L---- ----�
Sq. R._
_ft._
�I
f. Trowel/Sprayer coatings
Lin. ft.
ft. —
h. Transite board, wall board
^ftSq.
L--R�----
Lin. fi.
1
9q
�S
I. Other, please specify:
Lin. ft,R_
I. Specify
-
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
REQUIRED
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
IIb. Title
d. DEP Waiver # _
h. DOS Waiver #
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? 21 Yes ❑ No
B. Facility Description
1. Current or prior use of facility:SCHOOL ------�---�
2. Is the facility owner -occupied residential with 4 units or less? [_]Yes Z No
LTOWN OF MANSFIELD
3.
4.
■ anf001 ap.doc • 10/02
Asbestos Notification Form • Pa e 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 of General Contractor
c. City/Town
d. Zip Code___
_
f. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
L100139647
Decal Number
b. Address
e. Telephone Number area code and extension)_-__,.___
g. PoliCy Number _ —� �hExm Dale (mm/dd/
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):
NESM�_._�_.
a. Name of Transporter
c. City/Town
d. Zip Code
b. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES
a. Name of Transporter b. Address
a Ci //Town d. Z Code
II
4. IMINERVA ENTERPRISES INC
19000 MINERVA ROAD I
e. State
D. Certification
44688
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. Telephone Number
JIM DOYLE
Ea. —Name
t
oPoston/Title
11_
e. Telephone Number
q. Address
h. City/rown
b. Authorized SI nag_ture T
12/12/2011
d. Date mm/ddlylryb�
f. Representinq
I. Zip Code
anf001ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3