HomeMy WebLinkAboutOtis St. #330 - 5/31/2006Commonwealth of Massachusetts
1100032483
Asbestos Notification Form ANF-001 Decal Number
my I 1 ?On
Important;
pfa"A. Asbestos Abatement Description
When fining out
forms to the
1. a. Is this facility fee exempt city, town, district, municipal housing" '
tY P ' tY. P g 2Uthgrlty; flVOneTgCCf1pIE(.I
computer, use
only the tab key
residence of four units or less? ❑ Yes —7/] No
to move your
cursor - do not
b. Provide blanket decal number if applicable:
Blanket Decal Number
use the return
key'
2. Facility Location:
RICHARDSON
f330 OTIS STREET
a. Name of Facilit
b. Street Address
Mansfield
MA
102048 1
'
c. City/Town d. State
e. Zip Code I. Telephone Number
INSTRUCTIONS 3. Worksite Location:
1. All sections of this ' BOILER ROOM
form must be a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
completed in order
to comply with 4.
Is the facility occupied?
❑✓ Yes ❑ No
DEP notification
requirements of 310
CMR 7.15 5.
Asbestos Contractor:
and the Division
of Occupational
'NEW ENGLAND SURFACE MAINTENANCE
�a.
Safety (DOS)
Name
notification
requirements of 453
�WEYMOUTH
�02189�
CMR 6.12
c. City/rown
d. Zip Code
iAC000196
L DOS License Number
6 !JOHN P VALLIQUET
a. Name of OnSite Supervi
DAVE MAC DONALD
8.
0
9.
o
N
!FLIENVIRONMENTAL
05/30/2006
C.
0
10. a. What type of project is this?
o
LI Demolition
U Renovation
Repair
❑ Other, please specify:
11. a. Check abatement procedures:
o
Glove bag
❑ Encapsulation
Enclosure
❑ Disposal only
QLLJ
Cleanup
❑ Other, specify:
�! Full containment
Z
1850 WASHINGTON STREET
b. Address
7813372117
a. Teephone Number
g. Contract Type: ❑ Written ❑ Verbal
I I
'b. Describe
b. Describe
4 12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
anf001ap.doc • 10102 Asbestos Notification Form • Page 1 of 3
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
■
100032483
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
100 1120 —�
a. Total pipes or ducts (linear ft) b.-1 ota o er su aces square
c. Boiler, breaching, duct, tank
surface coatings
e. Corrugated or layered paper
pipe insulation
g. Spray -on fireproofing
i. Cloths, woven fabrics
k. Thermal, solid core pipe
insulation
j120
Lin. ft.
Sq. ft.
1100
Lin. ft.
Sq. ft.
�I
Lin. ft.
Sq, ft.
I�
Lin. ft.
Sq. ft.
Sq. ft.
Lin. ft.
14. Describe the decontamination system(s) to be used:
'AS REQUIRED
d. Insulating cement
I. TrowellSprayer coatings
h. Transite board, wall board
j. Other, please specify:
7-7
Lin. ft.
Lin. ft.
Lin. ft.
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
REQUIRED
16. Ftr Emergency Asbestos Operations, the DEP—and DOS officials who evaluated the ernergency:
a. Name of DEP Official
It. Title
c. Date (mm/dd/yyyy) of Authorization
i
d. DEP Waiver #
i
e. Name of DOS Official
I. DOS Official Title
Ig. Date (mm/dd/yyyy) of Authorization
It. DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c.-149, § 26,
27 or 27A—F apply to this project? ❑ Yes ❑ No
Its. Facility Description
1. Current or prior use of facility: MANUFACTURING FACILITY
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes 2 No
3.
4.
■ anf001 ap.doc • 10102
Asbestos Notification Fonn - Pace 2
L 'I Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
B. Facility Description (cont.)
5.
a. Name of General Contractor
c. City/Town d. Zip Code
f. Contractors Worker's Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
■
/100032483
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
rNESM LLP
a. Name of Transporter
c. City/Tom d. Zip Code
I
b. Address
I
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
;RED TECHNOLOGIES
a. Name of Transporter b. Address
3.
4. 1MINERVA ENTERPRISES INC
9000 MINERVA ROAD
I WAYNESBURG
c. Final Disposal Site Address
d. City/Town
OH
144688 1
e. State
f. Zip Code g. Telephone Numbe
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 and
310 CMR 7.15, and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
KEN FURTNEY
a. Name
b. Authorized Signature
05/09/2006
c. Positionmtle
d. Data mm/dd/vm)
�I
e. Telephone Number
f. Representing
I
q. Address
i. Zip Code
h. Cityrrown
0 anf001ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 N