HomeMy WebLinkAboutNoonan St. #12 - 6/6/2019ICI
Instructions 1. All
sections of this form
must be completed in
order to comply with
MassDEP notification
requirements of 310
CMR 7.15 and
Department of Labor
Standards (DLS)
notification
requirements of 453
CMR 6.12
MassDEP Use Only
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
A. Asbestos Abatement Description
Facility Location:
CHRISIINEOSLOWSIQ 12 NOONAN ST
a. Name of Facility b. Street Address
MANSFIELD
c. City/Town
MA 02048 6175016711
d. State e. Zip Code I. Telephone
CHRISTINE OSLOWSKI OWNER
g. Facility Contact Person Name h. Facility Contact Person Title
Worksite Location:
2. Is the facility occupied? ry a. Yes ry b. No
f100307707
Asbestos Project
I— Project Revision
I— Project Cancellation
ATnC
i. Building Name, Wing, Floor, Room, etc.
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)? W a. Yes I— b. No
4. Blanket Permit Project Approval, if applicable:
Date Received Approval ID #
5. Non -Traditional Asbestos Abatement Work Practice Approval,
if applicable: Approval ID #
6. Asbestos Contractor:
AIR SAFE INC
22VMLLOW STREET
a. Name
b. Address
CHELSEA
MA 02160 9783395361
c. City/Town
d. State e. Zip Code f. Telephone
AC000464
h. Contract Type: W I. Written r 2. Verbal
g. DLS License #
? JAIME EAMAYA
AS060847
a, Name of Contractor's On -Site Supervisor/Foreman
b. DLS Certification #
8 KEVIN CLIFFORD
AM000092
a. Name of Project Monitor
b. DLS Certification #
9 FU ENVIRONMENTAL INC
AA000144
a. Name of Asbestos Analytical Lab
b. DLS Certification #
10.
6/5/2019
6/6/2019
a. Project Start Dale (MM/DD/YYYY)
b. End Date (MM/DD/YYYY)
7AM - 5PM
N/A
c. Work Hours - Monday Through Friday
d. Work Hours - Saturday & Sunday
11. What type of project is this?
1— a. Demolition fJ b. Renovation r
c. Repair f d. Other - Please Specify:
Revised: 11/13/2013 Page 1 of
Massachusetts Department of Environmental Protection (100307707
N }- BWP AQ 04 (AF-001)
`l Asbestos Project #
,t
Asbestos Notification Form r Project Revision
r Project Cancellation
A. Asbestos Abatement Description: (cunt.)
12. Abatement procedures (check all that apply):
r a. Glove Bag r b. Encapsulation r c. Enclosure r d. Disposal Only r e. Cleanup
rV f. Full Containment J- g. Other - Please Specify:
13, Job is being conducted: r a. Indoors r b. Outdoors
14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
1. Linear Feet (Lin. Ft.)
b. Boiler, Breaching, Duct,
Tank Surface Coatings 1. Lin. Ft. 2. Sq. Ft.
d. Pipe Insulation
1. Lin. Ft. 2. Sq. Ft.
f. Spray -On Fireproofing
h. Cloths, Woven Fabrics
j. Insulating Cement
1. Lin. Ft. 2. Sq. Ft,
iNU'V�
1. Lin. Ft. 2. Sq. Ft.
15. Describe the decontamination system(s) to be used:
THREE CHAMBER DECON
650
2. Square Feet (Sq. Ft.)
c. Transite Pipe
e, Transite Shingles
g. Transite Panels
i. Other - Please Specify:
VERMICULITE
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin, Ft. 2. Sq. Ft.
650
1. Lin. Ft. 2. Sq. Ft.
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g)
6 MIL POLY
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:
a. Name of MassDEP Official b. Title of MassDEP
c. Date of Authorization (MMIDD/YYYY)
e. Name of DLS Official f. Title of DLS Official
g. Date of Authorization (MM/DD/YYYY) h. Waiver #
18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A-F apply to this r a. Yes r b, No
Project?
Revised: 11/13/2013 Page 2 of 4
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
B. Facility Description
1. Cut -rent or prior use of facility:
RESIDENTIAL
I100307707
Asbestos Project #
r Project Revision
f Project Cancellation
2. Is the facility owner -occupied residential with 4 units or less? r a. Yes r b. No
3 CHRISTINE OSLOWSKI 12 NOONAN ST
a. Facility Owner Name b. Address
MANSFIELD MA 02048 6175016711
c. City/Town d. State e. Zip Code f. Telephone
4 CHRISTINE OSLOWSKI 12 NOONAN ST
a. Name of Facility Owner's On -Site Manager b. Address
MIANSFIELD MA 02048 6175016711
c. City/Town d. State e. Zip Code f. Telephone
N/A N/A
5'a. Name of General Contractor b. A
N/A NIA 02048 1111111111
C. City/Town d. State e. Zip Code f. Telephone
N/A
g. Contractor's Worker's Compensation Insurer
N/A 12/31/2019
h. Policy # I. Expiration Date (MM/DDNYYY)
6. What is the size of this facility? 1,411 2
a. Square Feet b. # of Floors
Note: Temporary storage of Asbestos C. Asbestos Transportation & Disposal
containing waste 1. Transporter of asbestos -containing waste material from site of generation:
material is only
allowed at the place 1— a. Directly to Landfill or C b. To Temporary Storage Location/Transfer Station
of business of a DLS
licensed Asbestos
contractor or a transfer AIR SAFE INC 22 WILLOW ST
station that is c. Name of Transporter d. Address
permitted by
MassDEP and CHELSEA MA 02150 9783396361
operated in e. City/Town f. State g. Zip Code h. Telephone
compliance with Solid
Waste Regulations
310 CMR 19.000 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:
SERVICE TRANS GROUP 301 OXFORD VALLEY RD SUITE 803E
a. Name of Transporter b, Address
YARDLEY PA 19067 8779999559
C. Cityrrown d. State e. Zip Code f. Telephone
Revised: 11/13/2013 Page 3 of 4
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L�;t
Massachusetts Departrnrnt of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
I1010307707
Asbestos Project #
r Project Revision
f Project Cancellation
C. Asbestos Transportation & Disposal: (coat.)
3. Name and address of temporary storage location/transfer station for the asbestos
containing waste
material:
AIR SAFE INC 22 WILLOW ST
a. Temporary Storage Location Name b. Address
CHELSEA MA 02150 9783395361
c. City/Town d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA ENTERPRISES, INC
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8995 MINERVA DRIVE
c. Address
WAYNESBURG CH 44688 3308663435
d. City/Town e. State f. Zip Code g. Telephone
Note: Contractor must
sign this form for DLS
notification purposes 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."
P741
1. Name
PRESIDENT
3. Positiord ille
9783395361
5. Telephone
23 WYCHWOOD DRIVE
7. Address
MA
9. State
SrV
2. Authorized Signature
5/6/2019
4. Date (MM/DD/YYYY)
AIR SAFE INC
6. Representing
LITTLETON
8. City/Town
01460
10. Zip Code
Revised: 11/13/2013 Page 4 of 4