HomeMy WebLinkAboutNorth Main St. #204 - 12/13/2005Commonwealth of Massachusetts
� 100028762
Asbestos Notification Form ANF-001 neCBINumber
Important:
When filing out
A. Asbestos Abatement Description
p
forme on the
computer, use
1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
only the tab key
residence of four units or less? u Yes
to move your
cursor - do not
b. Provide blanket decal number If applicable:
use the return
Decal ral Number
key
2. Facility Location:
t'Q
AL RING CLEANERS
204 NORTH MAIN ST
MANSFIELD MA
OZ048
c. CdyRown d. State
e. Zip Code f. 77elepfiOnie Number
INSTRUCTIONS
3. Worksite Location:
1. All sectons of this
SAME
form must be
a. Building Na1te/BuIldirlg Laztton b. Brdlding 0
c. Wing 0. Floor e- Room
completed In order
IQ comply with 4.
DEG notldcetlon
requirement& of 310
CMR 7.16 $.
end the Division
of OaupaOonsl
Safety (Dos)
hotlfcalion
requirements of 463
CMR 6.12
6.
7.
$.
9.
Is the facility occupied? p✓ Yes ❑ No
Asbestos Contractor:
10. a. Whet type of project is this?
❑ Demolition ❑ Renovation
Q Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag
❑❑ Enclosure
Cleanup
❑ Full containment
8 Encapsulation
Disposal only
0 Other, specify:
81 ENDICOTT ST BLOG 32
Address
7$17823390
e. Telephuna Number
g. Contract Type:
b. Describe
VAT R TRANS
b. Describe
12. Is the job being conducted: 0 Indoors? ❑ Outdoors?
Gn Tn Tnp
N anf001ap.doc • 1ar02 Asbestos Notification Form • Page 1 of 3 ■
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Asbestos Abatement Description (cost.)
■
100026762
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
n I
0 ZI 2500
a. Tatill pipes or oum (linear o a o ter stn laws taquara
c. Boiler, breaching, duct, tank
surface coatings
a. Corrugated or layered paper
pipe Insulation
g, Spray -on fireproofing
I. Cloths, woven fabrics
k. Thermal, solid core pipe
insulation
14. Describe the decontamination system(s) to be used:
3 C14AMBER
d. Insulating cement
f. Trowel/Sprayer coatings
h. Trarraile Went, wall board
I. Other, please specify,
unSQ. fL
Lin,. Q. Sq. n,
Lin. ft. 1500
15, Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
16 MIL POLY LABELLED DOUBLE BAGS I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes [i1 No
B. Facility Description
1. Current or prior use of facility: COMMERCIAL
2. Is the facility owner -occupied residential with 4 units or less? O Yes ❑ No
3.
4,
■ anf001ap.doc• 10102
Asbestos Notification Form • Pa e, 2
�— Commonwealth of Massachusetts
' Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 18.OD0
B. Facility Description (cunt.)
5' a. Name of General Contractor
o. CI Room 0, Zip Code
I. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
100028762 ,
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
AIR SAFE, INC.
a. Name of Tran orter
C. Cltyn'own d. Zip Code
b. Address
0. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
3.
4.
11225 STATE ROUTE 45
cFinal Diwosal Site
OH 7 44432
e. State f. Zlp Code
D. Certification
The undersigned hereby stales, under the
JDAVID F.
penalties of perjury, that he/she has read the
a. Nang
Commonwealth of Massachusetts regulations
IVICE PRE
for the Removal, Containment or
e. Posllionn
Encapsulation of Asbestos, 453 CMR 6.00 and
761 762
310 CMR 7.15, and that the information
contained in this notification is true and correct
a. Tolophon
to the best of his/her knowledge and belief.
161 ENDIC
02062
I. Zip Code
IN e00010p doc • 10102 Asbestos NoUlimtlen FOnn • Page 3 of 3