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Home My WebLink AboutKingman Ave. #30 - 10/21/2014Oct 15 14 02:41 p Neal Cass Inc, i Commonwealth of Massachusetts Asbestos Notification Form A. Asbestos Abatement Descriptio Instructions 1. All sections of this fame must be completed in order to comply with MassDEP notficalon requirements of 31 D CMR7.15 and Department of Labor Standards (DLS) notification requirements at 453 CMR6.12 1, Facility Location: 10NGMAN RESIDENCE Name of Faulily MANSFIELD Citylrown PAUL WILUAMS Worksite Location: 2. Is the facility occupied? r Yes r 3. Is this a fee exempt notification (city, towl owner -occupied residential property of four MasdDEP Use Only 4. Blanket Permit Project Approval, if applicable: Date Received 5. Non -Traditional Asbestos Abatement Work Pr. if applicable: 2, Submit Original Form To: Commonwealth of 6. Asbestos Contractor: Massachusetts NEALCASSINC Asbestos Program P.O. Box 120087 Name Boston, MA 02112- DORCHFSTER P 0087 Cityrrown AC000810 DLS Ucense # 7, NEAL A CASS Name of Contractors On -Site SupervisodForeman g, JEFFHILL Name of Project Monitor 9, EWROTEST LABORATORY INC Name of Asbestos Analytical Lab 10. 1011812014 Project Start Dale (MMIDD/YYYY) 74 Work Hours - Monday Through Friday 11. What type ofproject is this? r- Demolition r Renovation C Repair ANF-001 17317941432 p.2 10020950D Asbestos Project N f— Project Revision r Pmlect Cancellation 30MNGMAN AVENUE Street Address 02048 6174597915 To Cade Telephone PAUL W LLLAMS Facility Contact Person Tile BASEMENT Building Name, wing, Floor, Room, etc. rict, municipal housing authority, state facility, or or less)? r Yes i—' No ron ID# 11ATORREYSTREET 02124 6172850004 Zip Code Telephone Contract Type: R—Written r—Verlml AS072613 DLS Certification # AM000203 DLS Certification# AA000128 DLS Certification it W2112014 End Date (MMIDDNYYY) 74 Work Hours - Saturday & Sunday Other -Please Specify: rage Oct 16 1402:41p Neal Cass Inc. 17817941432 p.3 Commonwealth of Massachusetts 100209500 Asbestos Notification For AM-001 Asbestos Project # F Project Revision iL j— Project Cancellation Lal A. ASDCSMS Aba[ement uescnpaaon: tcmu.r 12, Abatement procedures (check all that apply): 17 Glove Bag r Encapsulation (— Encic r Other - Please Specify: 13. Job is being conducted: r Indoors 14. Total amount of each type of asbestos Conta encapsulated: Linear Feet (Lin. FL) Boiler, Breaching, Duct, 400 Tank Surface Coatings Lin.Ft Sq Pipe Insulation r Disposal Oniv i Cleanup r' Full Containment r Outdoors ng materials (ACM) w be removed, enclosed, or 400 Square Feel (Sq. R.) Transke Pipe Lin. Ft Sq. Ft Transite Shingles Lin. FL Sq. FL Lin. FL Sq. Ft Spray -On Fireproofing Transite Panels L. Ft. Sq. FL Lin. Ft. Sq. Ft. Cloths, Woven Fabrics _1_ Other -Please Specify: Ft. Sq. FL Insulating Cement Un. Ft. Sq. Ft. Li. Describe the decontamination system(s) to I GLOVE SAG, FULL CONTAINMENT 16. Describe the containerintionldisposal 17. For Emergency Asbestos Operations, the ANDREWCOONEY Name of MassDEP Offical 10M42014 Date of Authorization (MMIODNYYY) orOLSOfficial 18. Do prevailing wage rates as per M.G.L. C. project? Lin. to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g): 1I Fn RAGGED. LABELED AND SNIPPED TO AN EPA LANDFILL EP and DLS officials who evaluated the emergency: INSPECTOR Title of MassDEP Official SE14.342 Waiver# Tide of OLS Official Waiver# § 26,27 or 27A—F apply to this I-- yet, r No Oct 151402:41p Neal Cass Inc. 17817941432 pA t" ! Commonwealth of Massachusetts Asbestos Notification For ANF-001 B. Facility Description I. Current or prior use oI'facility: RESIDENCE 2. Is the facility owner -occupied residential with 3. PAUL WILLIAMS Facility Owner Name MANSFIELD City/rovm 4.PAULWLUAMS !!100209500 �J Asbestos Project ft r— Project Revision r Project Cancellation or less? F. Yes r No 3010NGMAN AVENUE 02048 6174597915 Zip Code Telephone 3010NGMANAVENUE MANSFIELD Nl4 02048 6174597916 City/rmn le Zip Code Telephone 5.NiA NSA —_ NIA CitylTown Note: Temporary NIA stomgeof Asbestos Contractor's Workets CompensaOon Insurer containing waste NIA material Is only allowed at the place policy# of bu4lnea$ of a DLS licensed Asbesms 6. What is the size of this facility? eantractor or a transfer station that Is permitted ey MassDEP and C. Asbestos Transportation & .oersted in compliance with solid Waste Regulations L Transporter of asbestos -containing waste r 310 CMR 1 a. a00 j' Directly to Landfill or ry To Ten NEAL CASS 00000 0000000000 In Code Telephone 61W066 Enpira0on Date (MMIDDNYYY) 1539 1 Square Feet #oi Floors from site of generation: Storage Loeationrrransfer Station IIATORREYSTREET DORCHESTER Ma 02124 6172650094 City/Town 1e Zip Code Telephone 2. If a temporary storage location/transfer station is used, Iiscname of transporter of asbestos containing waste material from temporary storage locationitr insfer station to final disposal site: SERMCE TRANSPORTER GROUP 56 PYLES LN Name of Transporter Address NEWCASTLE U 19720 0000000000 City7Town SI to Zip Code Telephone rage Oct 151402:42p Neal Cass Inc. 1 781794 1432 p.5 Commonwealth of Massachusetts Asbestos Notification For ANF-001 nore:commcwrmust C. Asbestos Transportation & Disposal: sign this form for Di notification puryoses 3. Name and address of temporary storage material: 49TERRACE STREET Temporary Storage Locaflon Name BOSTON Cityrrown 4. Name and location of final disposal site (� MINERVAENTERPRISFS Final Disposal Site Name 9000MINERVAROAD Address WAYNESBURG City?own D. Certification "I certify that I have personally examined the foregoing and am familiar with the information contained in this document and all 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 aware that there are significant penalties for submitting false information, including possible fines and Imprisonment. The 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." MA State f �zassoo _� I Asbestos Project N j" Prpicct Revision r ProjcctCancellation station for the asbestos containing waste 49TERRACESti Address 02124 0000000000 Zip Code Telephone landfill): FRANK S UFANO Final Disposal Site Owner Name CH 44688 0000000000 Stal i lip Code Telephone ,Ca EMAN PAMELACOLEMAN Authorized Signature TRA OR 1011512014 Data (MMCDMYY) rifle i004 NEALCASS, INC. Representing to ;R STREET DORCHESTER City/Town 02124 Zip Code