HomeMy WebLinkAboutNorth Main St. #262-266 - 10/2/2003Commonwealth of Massachusetts
100001008
0
11.81 Number
Asbestos Notification Form ANF-001 ... ......
Affix Asbestos
Notification Decal
Here
............
Important:
A. Asbestos Abatement Description
When filling fail
forms an the
IN, is this facility fee exempt - City., town, district, municipal housing authority, owner -occupied
computer, use
onty the lob key
residence of four units or less? j!,. Yes No
to move your
cursor, do not
It. provide blanket decal number it applicable:Blanket
Oeoal Number
use the return
key.
2. Facility Loco tici n:
.... ... .. .... .
MARCO CRUGNALE
262-260 NO, MAIN ST ------- — - —
y
a; Name
A.Atnss! k(lit!en
MANSFIELD MA
0264e '(508) 337-014
d. Siii
3. Worksits Location.
INSTRUCTIONS
1. AN sections of this
form must be
SAME
. .......
complaW In order
to comply with 4.
DFP notification
requirements of $10
CMR 7.15 5.
and the Division
olowupswal
Safety (DOS)
nollitation
requirements of 453
GMR 6,12
6.
7.
a.
9.
Is the facility occupied? V: Yes '.* No
Asbestos Contractor:
AIRSAINE INC
... . ........
0, Name
NORWOOD 02002
C. City . qPWA Jf. tip Code
AC000404
........ ....... ....
;JAIME E, AMAYA
NIA
is,Ns�iof "1�mqxt 4 IN OLE—,
a:.Na
A. ..... " AneL
110/0212003 --------
In
..... ..........
. S___. .7:00.5:00
10. a. What type of project is this?
Demolition Renovation
';o. Repair Other, please specify:
11. 2. Check abatement procedures:
'.;;'Glove bag Encapsulation
Enclosure Disposal only
Cleanup Other, specify:
Full containment
61 ENDICOTT ST SLOG 32
.,. .. . . ...... ............. ...
it, Address
7811623390
;;"-T —6 W p--h, * oi4 , dumber* -
g, Contract Type: Written Verbal
........ ..
A$060547
pn Number
6 P,
11010212003
It, but It
0. Describe
b. Doambe,
12. Is the job being conducted: 1V-Indoors? Outdoors?
0 anfOolap.doc - 10102
A,bestus Noftfkadon Form - Pepe 1 013 0
0 Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100001008
Daul Number
A. Asbestos Abatement Description (cunt.)
13, Total amount of each type of Asbestos Containing Materials (ACM) to be removed, endosed, or
,encapsulated :.. .............� ..
a. Tolel pipes a dude (linear tl) b',7otdtbtrier surTtiBee f6quaro R)
c. Boiler, breeching, duct, tank
surface coatings
_.........
d. Insulating consentso
,
a, corrugated or layered paper
pipeinsulation
Lin.f(:_
Sq_ft. .
r. 7reweUSpreyer Coalinga
q, Spray -on flroptoofinq
Lin °h.' .
,�--�---
It, Trantxte board, wall board
_Linft.-^-%
..Sq_
L Cloths, woven fabrlw
.•
J. Other, please specify:
_...__....:
'. .... ......
It. Thermal, solid ems pipe
'_*_._....,.___...........,._.-..._._..______.__—__...,...._......._—__.
insulation
LIn. R:
Sq. R.
t. SP�dY
14. Describe the decontamination system(s) to be used:
3CHAMBER
15. Describe the con(ainerizationldisposal methods to comply with 310 CMR 7.15 and 453 CMR
OLY SAO WITH LABEL
15. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
c. Data mmldiV or AulhohzaXen d. DEP Walvera
i
q. Data (mmlddlyyyyl or Autnadxetloit
0 IFik a"ITI'de—.-'---`.. --
'5:03 Waiver d
17. Do prevailing wage rates as per M.G.I. c. 149, § 26, 27 or 27A-F apply to this project? !`Yes ;✓; No
B. Facility Description
1, Current or prior use of facility! RESIDENTIAL
2. Is the facility owner-=upled residential with 4 units or less? R Yes
;SAME
3. ...—. --____..- -- ......... .......... ....._ - ----- --
^Fade Owner Neme
o. Ci /Town d. 11 Cads e. Telephone Number jams mds efld4.
eMMdan
e. Name of Fidlity Owne�a OnSile ManodM _„ b. On -Site ManegN Adereas
_............_ ..........—*. ,........., ... 'd .. ._
(. Cilyrtown e. ilp Cove
a. Telephvtte Number (aroa txx7-e and extension)
N enloolap.doe • 1o/U2 Asbestos rlaeaoatlon Form • Page 2 at 3 0
Ll
Note: Transfer
Stations must
comply with the
Said waste
olvwlon
Regulations 319
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
1000091108 _
Oecal Number
B. Facility Description (cont.)
5- a. Name of Gs rat Conhactor b. Address
c_Ci Hawn d. Zi Cods _ e, TgM ors Number (area code and e■tanalonl
f. Contrectare Worker's Comp. Insugr g, pdby Numher .�.—_ h. EItp.Oal- mMldlyyyyl,
i I
6. What is the size of this facility? ----------_..._....
•a. were Fes b. Number of floor
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (If necessary):
i
...... ,............._.. .._ ....._..—__._. ;b, Address
e. ClylTown d. Zip Gads e. Telsphane Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
a, Namw.ofTlanapoder. .......... _,.,....... .......-,-..-..M._.. b:.f1_d,Ufase,...... ....__—.___........,
c.. ClrylTmrn.._..... ............................... _?: �?R.�,4?1.�...., ..°__ T.elephone.Number
3.
e. Rsruss TranaMr Station and Owner
16oee_... ..
4. .BFI IMPERIAL LANDFILL
...........
a. Final Oie ea15 b L&cation Nemi
PO BOX 47-11 BDGGS ROAD
o.,FinalDkQoeetSitpAgdnse___._„__.. _ __
.PA 16126 —
e. State i, ZiD Cods
D. Certification
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos, 453 CMR 6.00 end
310 CMR 7.15, and that the information
contained in this notification is true and correct
to the beat of hie/her knowledge and belief.
■ anfWlap.doo-10/02
b. Address -
e. Tsle one Number
........ ..._ .._... ._ ..,.,. __... ----
......... .........
D. Final Disposal Sits Loeallan Owers Neme
IMPERIAL
g. Tebphone Number
DAVID F. WALSN
s: hin!!�e ..............
b. AuthorlZed S.ipmture...,
VICE PRESIDENT
..
_...,.....
i06/17/2003
td.
e eultlen/rtN V W_..._
- Dsts�m,�
I(761) 762.3300
:AIR SAFE INC
NORWOOD 02062
n, Clly/Tawn 1. Zip Code
t�
Asbestos Notification Form - Fags 3 of 3