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HomeMy WebLinkAboutNorth Main St. #150 - 4/1/201503/23/2015 03:35PM 5442 DAVE WALSH PAGE 02/06 AQ 04 - Asbestos Removal Notification F.otm ANF-001- Transaction #729672 Page 1 of 2 Commonwealth of Massachusetts 100218B03R7 Asbestos Notification Form ANF-001 Asbestos Project Number LEI I R Project Revision Project Revision Notification ��n� L ] - Project Canoellatlon A. Asbestos Abatement Description 1, Facility Location: LOD 60ARIND CONTRACTING 7. '1Sb NORTH MAIN ST `. Name of Faclllty Street Address "} MA Io2048W�ry Y81-341-6736 City/Town Stets Zip Code Telephone SAME _ � ;OWNER Instructions t. At Fadlity Contact Person Name Facility Contact Person The sections at into form moat Worksite Location: LBASEMENT be oompleled in order to Building Name, Wing, Floor, Room, etc. comply with MassDEP 2. Blanket Permit Project Approval, if applicable: -�---� nogacadun reauiramam5 of 310 CMR 7.15 and Approval to# Department of Later 3. Nan -Traditional Asbestos Abatement Work Practice Approval, if applicable: Standards (DLS) Approval to # notification requiremenle 'M31/2015 of4$3CMRa.12 t....._...............-. �p ,.........._. __._. Project start Date,(Mwo[)NYYY) End Doze(MWDD(YYYY) 7AM -6PM �MaaaDEP Use �Only vyoik Ha4rs" Monday Through Friday Work Hours - Saturday&Sunday Date B. Other Project Revisions: 2. Submit Original Form To: Commonwealth of Massachusetts Asbestos Program P.O. Box 120037 Boston, MA 02112- 0057 Note: Temporary storage of Asbestos containing waste maledal is only allowed at the place of business of a DLS licensed Asbestos C. Certification "I canify 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 these indlylduels Immediately responsible for obtaining the information, I believe that the Information is two, aaurate, and complete. I am aware that there are significant penalties for submitting false eentreclorotatrensfer Information, including possible fines and station that Is permitted imprisonment The undersigned hereby by MaaaDEP and stelae that 1 have read the operated in compliance Commonwealth of Massachusetts with Solid Waste regulations governing asbestos Regulations 310 CMR abatement(453 CMR 6.00 promulgated 12.000 by the Deparlmentof Labor Standards and 31 a CMR 7.15 promulgated by the Department of Environmental DPw.,.�....,...n.—� I — -- Name Authorized Sionalure ffP--777= Posifianrriva 701-782-3390 Telephone Date (MM/DD79YYY) AIRSAP fit Representing 2 WILLOW ST CHELSEA Address Cityrrown - State rzi sd----_ ---�-�---] Zip Go" https://edep-dep,mass.gov/WebForms/Asbestos/BWPANFOOI.aspx 3/23/2015 03/23/2015 03:35PM 5442 DAVE WALSH PAGE 03/06 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #729094 Page 1 of 4 Commonwealth of Massachusetts 10o2165e3 »` •' Asbestos Notification Form ANF-001 Aaaestos Protect Number ?,,AA Project Revision L` M Project Cancellation A. Asbestos Abatement Description 1. Facility Location: LOU GUARINO GONYRACTIN_G Name of Facility ......._ MANSFIELP ! "'' MA U Cltytrmn State Facility Contact Person Name Instructions 1. All Wcrksite Location: secilons orthlafomt must be completed in order to 2 is the facility occupied? Ives No comply with MasaDEP ��i in� It 60 NORTH MAIN ST Street Addreas 2048 _.._.__—i 781,1'41-8736. .,.�...�= Zip Code Telephone IOWNER Fa011itY Contact Person Tile ,BASEMENT��'""'—_..__..._—� Building Name, Wing, Floor, Room, etc, notification requirements of 310 CMR7,15 and 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner- Oepenmenlof Labor occupied residential property of four units or less)?In Yea FM No Stonaeroa me) nonncelan requb mer4e 4. Blanket Permit Project Approval, if applicable: of 453 CMR 6.12 AOMOvanP A 5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable: MassDEP Use Only Approval ID # i.-.--� 6. Asbestos Contractor: --I Date Received r"""""'""'"-'"-- 2. Submit Original Form TO: commonwealth of Massachusetts Asbestos Program P.O. Box 120007 Boston, MA 02112- 00e7 Name �_�___�_�...,........ Address.,.,......,...,.....«....,.......M.,....»...._. CitylTmvn Slate Zip Code Telephone AC000464 Contract Type: nWrtJenj!i� Verbel� DLS License M Name of 006t actv's On-Slee SUPerv1900FOMMen 8. L__.__.___________.._________— -------- _---------- .__._.__ Name of Project Monitor Nome of Asbestos Analytical Lab Project Start Date (MM/DD/YYYY) --{ pAM .apm Work Hours - Monday Through Friday PLB CeNgcatwn � M0a07B7 DLS CsrdOcation 0 000128 -i DLS Ce1l00alOh # 4mvzo15 ...i End Date (MONobNYYY) Work Hours, Saturday A Sunday https://edel).det).mass.gov/WebForms/Asbestos/13WPANF'001.aspx 3/19/2015 03/23/2015 03:35PM 5442 DAVE WALSH AQ 04 _ Asbestos Removal Notification Form ANF-001».Transaction #729094 PAGE 04/06 Page 2 of 4 �0 Dem iltlan i©J Renovation I FI Repair i, IjOther-phase Specify: LL..::1� .�. um.,� 12. Abatement procedures (check all that apply): U; Glovo Bag Q�Encspsulation j�enrAosure'�f�"IlDisposal Only QlCleanup T u j Full containment rr_I Other - Please Specify (LJJ —_..-.._...»«......_ _........,..u..x---...,_.»»..._.,.,..a�x„w.x..-....-•-•---. i__..uwa.vnmtan,wv�._�_.�..»_..-....nn,x.uwewvamawsW�__.».,unxmr_.w.warvoouwam 19. Job is being conducted: i Q�maao a �]iou doors r_. L«.. 14, Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or encapsulated: Linear Feet (Lin. Ft.) Square Feet (Sq. FL) sailer, Breaching, Duct, Tank = ag_ J Transile Pipe --,„,—,I LJ Surface Coagngs Un. Ft. Sq, FL Lin. Ft. Sq, Ft Pipe Insulation Tranite Shingles [— Lin. Ft sq, Ft. Lin. Ft. Sq. Spray -On Fireproofing I Transits Panels t t....-.--J .-Ft. --'--I Lin. Ft. Sq. FL Sq. Lin. FL Sp. Ft. ClOns, Woven Fabrics 1� -T-� Other -Please Specify; tip. Ft. Ft. Insutating Cement �--'1Sq. Lin. Ft. Sq. FL Lin. Ft. Sq. Ft. 15. Describe the decontamination system(s) to be used; 16. Describe the containerizabon/disposal methods to comply with 310 CMR 7,15 and 453 CMR 6.14(2) 17. For Emergency Asbestos Operations, the MassDEP arid DLS officials who evaluated the emergency: Name of MassDEP Official Date of Authorization (MMIDDIYYYY) ___.___._..............____._._._-.._-..-_._...__._____—.__.. Name of DL5 Official Date of Authorization (MM/DD/YYYY) Tllle of MassDEP official } Waiver M -._....,..M.....------------------------ ._.__._______...._-_.____. Title of DL5 Official Waiver# 18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—P apply to this project? 13. Facility Description I Y@B J INo ❑, 11. httns!//eden.den.maa.q.pnv/WehForms/Asbestos/RWPANFOOI .agnx 3/19/2015 03/23/2015 03:35PM 5442 DAVE WALSH AQ 04 -Asbestos Removal Notification FQvm ANF-001- Transaction #729094 PAGE 05/06 Page 3 of 4 of Aaheas containing C. Asbestos Transportation & Disposal Baste material is only slowed at the place of business of a DLS lima .d Asbestos contractor w a Irensrsr allUon Matta plemilled by MwsDEP and operated in compliance win Sold Waste Reguleliahs 010 CMR 19.000 Note: Contiactwmust SPn this mrm rw Us notificalkn purposes 1. Transporter of asbestos -containing waste material from site of generation: I � DhatAly to Landfill or j U! To Temporary smrege Locauon/Transfer stason AIR SAFE Name of Transporter GMBLSLA _------- - MA citylTdwn state @2 ....__..__ WILL _...«.._.__. ..____._.__.__................. Addreas 102180 -� 7e1-78&3ae0 _ Zip code Telephone 2. If a temporary storage locationitransfer station is used, list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: TSERVICE TRANS y 8 PYLES LANE i,.--"___r....._.�,....»...-.....,........«..._.,..ww.o...._........,....«,.t..,a-.._.._.....__..._ww,.e.....�...........w,..wo...,.-�_--..... Name of Transporter Address NEW CASTLE g DE 1972 ^q [°877-989�55B Clty/Town State Zip Cede Telephone 3. Name and address of temporary storage location/transfer station for the asbestos containing waste material: Temporary storage Wasson Name City/Town state n ISAMEn.........r.......»....w..�..........,..-.�...w.«�� Address "0215,ow•- '( i7et-Ts2•aseo Zip Code Telephone 4. Name and location of final disposal site (asbestos landfill): _ __.y MINERVA .............___. .1 Final Disposal Site Name 9000 MINERVA RO Address WAYNESBURG � OH Gityfrown state (MINERVA ENTPR Final Disposal Site Owner Name !94Ba8 930•aee-1dS5 �� � Yip Code Telephone Name Authorized signature (vP _STY-_--�v.•_�____J .__.�—__•.w«..._. 71 Position/Title Cate (MM11DDNYYY) Telephone Represenfing CHELSEA ...............'.'.,,-� Address Chyfrown -----ry State Zip Code bttos://edet).del).mass,gov/WebForms/Asbestos/BWPANFOOl.aspx 3/19/2015 03/23/2015 03:35PM 5442 DAVE WALSH PAGE 06/06 AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction #729094 Page 4 of 4 D. Certification °I certify that I have personally examined the f0ftoing and am familiar v4th the INOMIAHOn contained in this document and all attachments and that, based o0 my inquiry of those Individuals immediately responsible for obtaining the InfO(mation. I believe that (he information is We, accurate, and complete. I am aware thatthera are significant penalties for eubmitdng false information, including possible gees and Imprisonment The undersigned hereby states that I have read the Commonwealth of Massachusetts tegblallona governing asbestos abatement (453 CMR 3,00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the beparment 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." https://edep,dep.mass.gov/WebForms/Asbestos/BWPANFOOI,aspx 3/19/2015