HomeMy WebLinkAboutEast St. #560 - 11/30/201510/1212DIS
Instructions 1. Ali
sections of this form
must be completed In
order to comply With
MamDEP notification
requirements of 310
CMR 7.16 and
Department of Labor
AQ 04- Asbestos Removal Nofification Form ANF-001- Transaction #781179
Commonwealth of Massachusetts 100230679
Asbestos Notification Form ANF-001 Asbestos Project Number
Project Revision
[ Project Cancellation
A. Asbestos Abatement Description
Facility Location:
mmRTONRESIDENCE
I t560 FAST ST �l
Name of Facility
Street Address
• ® 2046 06-0004000
MANSFIELD _
City?own
State Zip Code Telephone
UPERVISOR
SAMUELJ NIGRO IIII
Facility Contact Person Name
Facility Contact Person TiBe
Worksite Location:
�4TTIC
Building Name, Wing, Floor, Room, etc.
2. Is the facility occupied? ki Yes DNo
3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or
owner -occupied residential property of four units or less)? ZYes 0 No
Standards (DLS) 4. Blanket Permit Project Approval, if applicable:
notification requirements
of 453 CMR 6.12 5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable:
�1
�Approval ID #
t.
Approval ID #
6, Asbestos Contractor:
MassDEP Use Only
DUDLEY SERVICES INC
3 DUDLEY STREET PO BOX 132
Date Received
Name
Address
RLINGTON ®
2176 781-643-4328 _
Cityrrown State
Zip Code Telephone
2, Submit Original Form
C000112 ^7
Contract Type: i�' Wrfttan �� Verbs
To: Commonwealth
DLS License #
Of Massachusetts
P.O. Box 4062
7, ISAMUEL J NIGRO III
5032602
Boston, MA 02211
Name of Contractor's OmSite Supervisor/Foreman
DLS Certification #
8, ENVIRO-SAFE ENGINEERING DBA
000131
Name of Project Monitor
DLS Certification If
g, ENVIRO-SAFE ENGINEERING
—, 000131
Name of Asbestos Analytical Lab
DLS Certification #
111/3012015
10. 11/20/2016
Project Start Date (MWDD/YYYY)
End Date (MWDD/YYYY)
8AM-5PM
AM pvt
Work Hours - Monday Through Friday Work Hours - Saturday & Sunday
11. What type of project is this?
EDemotWon RenovationRepair Other -Please Specify:
12, Abatement procedures (check all that apply):
Glove Bag Encapsulation E]Encloaure []Disposal Only Cleanup E Full Containment
Other- Please Specify:--»,.-___-.._��.-W �� ____,_,_I
j.-
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10/12/2015
AO 04 - Asbestos Removal Notification Form ANF-D01- Transaction WIN 179
13, Job Is being conducted: a Indoors ElOutdoors
14. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
F--
Linear Feet (Lin. Ft)
Boiler, Breaching, Duct, Tank
Surface Coatings
Pipe Insulation
Spray -On Fireproofing
Cloths, Woven Fabrics
Insulating Cement
15.
I0
Ft.
Ft.
rrLin.
L—
��sq.
J�
Lm, Ft.
Un. FL
Sq. FL
Sq. FL
�0
Lin. Ft.
Sq. Ft
�E=
Lin. Ft.
Sq. FL
1500
Square Feet (Sq. FL)
Transte Pipe
Transfie Shingles
Transits Panels
Other - Please Specify:
7-
Lin. Ft.
Sq, Ft.
FE=
Lin. FL
Sq, Ft.
F-0
Lin. Ft.
Sq. Ft.
ERMICULITEI 1500
Lin. Ft. Sq. FL
Describe the decontamination system(s) to be used:
CONTAINMENT BARRIER WITH CLEAN ROOM USING NEGATIVE AIR SYSTEM AND HEPA
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.1
4(2)(9):
WET ASBESTOS PROPERLY SEALED IN SIX MIL POLY BAGS PLACARDED FOR ASBESTOS
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the
emergency
Name of MassDEP Official Title of Ma"DEP Official
��
Date of Authorization (MMIDD/YYYY) Waiver N
Name of DLS Official rTitle of DLSOfficial
i
Date of Authorization (MM/DDIYYYY)
Waiver N
18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this Yes o No
project?
B. Facility Description
1. Current or prior use of facility:
EsiDENTIAL DWELLING
2. Is the facility owner -occupied residential with 4 units or less?
Yes D No
3. ISAME
IAME
Faclty Owner Name
Address
SAME
MA 0000 �_
000-000-0000
CIty/Town
State Zip Code
Telephone
4. INA
I A
Name of Facility Owner's On•Ske Manager
Address
NA
MA DOOtl
000.000.0000
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10/12WS
AO 04- Asbestos Removal Notification Form ANF-001- Transaction #781179
Note; Temporary storage
of Asbestos containing
waste malarial is only
allowed at the place of
business of a DLS
licensed Asbestos
contractor or a transfer
station that is penlued
by MassDEP and
operated in compliance
with solid Waste
Regulations 310 CMR
19.000
Cotrown
5. [R—A _
Name of General Contractor
State
J�
Zip Code
NA
Address
Telephone
NA
MA
0000
00.000-0000—'�
Cityrrown
State
Zip Code
Telephone
IM MUTUAL
—�
Contractor's Worker's Compensation Insurer
7026686
7/0912016 —��
Policy #
EKpira0on Date (MM/DD/YYYY)
6. What is the size of this facility?
1568
Square Feet # of Floors
C. Asbestos Transportation & Disposal
1. Transporter of asbestos -containing waste material from site of generation:
ElDirectly to Landfill or 211 To Temporary Storage LocalbNrratlsfer Station
DUDLEY SERVICES 116ONEWBOSTONST
Now of Transporter Address
OSURN 1801 17.981-4260 �l
City/Town state Zip Code Telephone
2. If a temporary storage location/transfer station is used, list name of transporter of asbestos
containing waste material from temporary storage location/transfer station to final disposal site:
.O.B. ROLLOFF FOX 6037
Name of Transporter Address
HELSEA vt� 2160 17-387-1495
Cltyrrown Stale Zip Code Telephone
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
Temporary Storage Location Name Address
NA I MA 0000 0-000-0000
Cityrrown State Zip Code Telephone
Note: Contractor must 4. Name and location of final disposal site (asbestos landfill):
sign this forth for DLS f URNKEY LANDFILL
J 11MASTEMANAGEMENT I I
notification purposes Final Disposal Site Name
Final Disposal Site Owner Name
7 ROCHESTER NECK RD.
Address
ROCHESTER1
H� 3869 00.847-5303
Cityrrown
State Zip Code Telephone
D. Certification
"1 certify that I have personally examined
the foregoing and am famillor with the
Information contained in this document
and at attachments and that, based on
my Inquiry of those individuals
Immediately responsible for obtaining the
information, I believe that the information
is true, accurate, and complete. I am
SAMUEL NIGRO,_,
Name
PRESIDENT
Position(rWe
617-981-4260
Telephone
160 NEW BOSTON ST,^
UEL NIGRO
Authorized Signature
10/1212016
Date (MM/DD/YYYY)
DUDLEYSERVICES
Representing
OBURN
ht4slladep.tlep.mass.govMebForms/Ashestosl13WPANF001.aspx 3K
10r12Y1015 AQ 04- Asbestos Removal Nobfication Form ANF-001- Transaction #781179
aware that there are significant penalties Address Cbyrrown
for submitting false Information, Including A 01803
Possible fines and imprisonment The State Zip Code
undersigned hereby states that I have
read the Commonwealth of
Massachusetts regulations governing
asbestos abatement (453 CMR 6.00
Promulgated by the Department of Labor
Standards and 310 CMR 7.15
Promulgated by the Department of
Environmental Protection), and that I am
aware that this permit application or
notification Shall not be deemed valid
unless payment of the applicable fee is
made."
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