HomeMy WebLinkAboutForbes Blvd. #171 - 12//23/2004Important:
When filling out
forms on the
computer, use
only the tab key
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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
Safely (DOS)
notification
requirements of 453
CMR 6.12
Commonwealth of Massachusetts
Asbestos Notification Form
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 ❑✓ No
b. Provide blanket decal number if applicable: Blanket Decal Number
2. Facility Location
1OFFICE BUILDING
a. Name of Facilih
Y_ MANSFIELD � MA
c. City/Tom d. Slate
171 FORBES'BLVD.
b. Street Address
02048
e. Zip Code I. Telephone Number
3. Worksite Location:
SUITE #4500 0
a. Building Name/Building Location b. Building # C. Wing d. Floor e. Room
4. Is the facility occupied? 0 Yes ❑ No
5. Asbestos Contractor:
EAST REMEDIATION
1253 LOW STREET SUITE 224
b. Address
IRYPORT
16173899188
M d. Zip Code
e. Telephone Number
IKEVIN BOUSQUET I
6 JJUAN JOSE MEDINA
7 JRHODE ISLAND ANALYTICAL
Q
Q
10. a. What type of project is this?
❑ Demolition ❑✓ Renovation
❑ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑ Enclosure
❑ Cleanup
❑✓ Full containment
❑ Encapsulation
❑ Disposal only
❑ Other, specify:
g. Contract Type: ❑✓ Written ❑ Verbal
b. Describe
b. Describe
12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
anf001 ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 0
Commonwealth of Massachusetts
l-
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
■
100012173
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
enca sulated:
�� 600
a. Total pipes or ducts (linear ft otal otner surfaces square
c. Boiler, breaching, duct, tank
surface coatings
e. Corrugated or layered paper
pipe Insulation
g. Spray -on fireproofing
I. Cloths, woven fabrics
k. Thermal, solid core pipe
insulation
d. Insulating cement
Lino
f. Trowel/Sprayer coatings
Lin
h. Transite board, wall board
, ,�
I. Other, please specify:
14. Describe the decontamination system(s) to be used:
THREE -CHAMBERED DECNTAMINATION FACILITY WITH SHOWER
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (n):
IACM WILL BE WET (HAND TO BAG). ACM WILL BE PROPERLY LABELED, PACKAGED AND T'
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency
a. Name of DEP Official _ b. Title
c. Date mm/dd/ of Authorization d. DEP Waiver #
NIA
e. Name of DOS Official i. D S Official Title
a_ Date (mm/dd/vvvv) 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 ❑✓ No
B. Facility Description
1. Current or prior use of facility: OFFICES
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No
3.
FA
■ ari sp.doc-10102
1116 FLANDERS ROAD SUITE #2000 1
1116 FLANDERS ROAD I
e.
Asbestos Notification Form - Pa iki
Ee
Commonwealth of Massachusetts100012173
Asbestos Notification Form ANF-001 Decal Number
B. Facility Description (cont.)
NIA
5' a. Name of General Contractor
C. Cil /town d. Zip Code
f. Contractor's Worker's Comp. Insurer
6.
What is the size of this facility? 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):
NORTHEAST REMEDIATION 1253 LOW STREET, SUITE #224
Note: Transfer
a. Name of Trans orter b. Address
Stations must
NEWBURYPORT 01950 617)389-9188
comply With the
c. City/Tom d. Zip Code e. Telephone Number
Solid Waste
Division
2.
Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
Regulations 310
CMR 19.000
WASTE MANAGEMENT NEET 1 1209 PICKERING STREET, PO BOX 144
43
§!
a. Refuse Transfer Station and Owner
C. Cit rrown d. Zip Code
TURNKEY LANDFILL (WASTE MGT NH)
a. FInaI Dis osal Site Location Name
7 ROCHESTER NECK ROAD
rn
O
o
D.
N
e. State
Certification
272-3867
ESTER
03839 (603)332-2386
f. Zip Code g. Telephone Numt
The undersigned hereby states, under the
ISARAH MARCONI
penalties of perjury, that he/she has read the
a. Name
O
Commonwealth of Massachusetts regulations
PROJECT COORD
for the Removal, Containment or
c. Position/rille
Encapsulation of Asbestos, 453 CMR 6.00 and
(617) 389-9188
310 CMR 7.15, and that the information
contained to this notification is true and correct
e. Telephone Number
to the best of his/her knowledge and belief.
1253 LOW STREET
O
-
. Address
NEWBURYPORT
a
h. Cilyrrown
Z
Q
anf001 ap.doc
• 10/02
0
NER
01950
i. Zip Code
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Asbestos Notification Form • Page 3 of 3