HomeMy WebLinkAboutPratt St. #90 - 11/18/2016AQ 04 - Asbestos Removal Notification Form ANF-001- hansaction... Itttps:/Iedep.dep.mass,gov%Webl;ornrs/Asbestos/BWPANFOOI.asl>t
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Massachusetts Department of Environmental Protection I00^6::e71R2
BWP AQ 04 (ANF-001) Asbestos Project#
Ll
Project Revision Notification Project Revision
i) Project Cancellation
i
A. Asbestos Abatement Description
1, Facility Location:
GEORCE SI'FALL
t
90 PRATT ST
_--" - -
a Name of Facility
bStreet Address
_
MANStILL D
-..
Mn 970•18 SOU-341-fl474
c. Ciry/Town
d Slate e. Zip Code f. Telephone
GLORGESUAt (:.
F ilit C IP. N _. _.
_ _ .OWNER..
_ h F ill C _ .tP Till
Instructions I. All
g au y on aC arson ame
act I y mine Lfeon e
soclfws of lhls form must
Workslte Location:
-exr S4LLI(AFS
be complated in order to
I. Buitding Name, Wing , Floor, Room, elo,
compiywilh fdassDEP
_
norrs:alme mqulremems
2. Blanket Permit Project Approval, if applicable:
_..
of,mo Civil 7. isand
Approval to #
Department of fares
3, Non -Traditional Asbestos Abatement Work Practice Approval, if applicable:
Standards(DLS)
_.. _ _
Annowal ID # _ .-..
notification requirements
11/1612015. -,. _,.
11MO12016
of 453 CTv9'. 0.12
a. Projeot Start Dale (MMIDDNYYY)
b. End Dale (MM/DDIYYYY)
7A&I GPM NA
c. Work Hours -Monday through Friday d. Work linurs " Saturday & Sunday
MassDEP Use Only
Date Received B. Other Project Revisions:
2. Submit Original
-
Form To:
Commonwealth of
Massachusetts P.O.
Box 4062 Boston, MA
C. Certification
02211
"I certify that I have personally examined
the foregoing and am familiar with the
Note: Temporary
information contained in this document
storage of Asbestos
and all attachments and that, based on
containing waste
my inquiry of those individuals
material is only allowed
immediately responsible for obtaining
at the place of
the information. I believe that the
business of a DLS
information is true, accurate, and
licensed Asbestos
complete I am aware that there are
contractor or a transfer
significant penalties for submitting false
station That is permitted
Information, including possible lines and
by MassDEP and
mrijusomnent The undersigned hereby
operated in compliance
states that I have read the
with Solid Waste
Commonwealth of Massachusetts
Regulations 310 CMR
regulations governing asbestos
19,000
abatement (453 CMR 6 00 promulgated
by Zile Department of Labor Standards
and 310 CMR 7.15 promulgated by the
Nate; Contractor must
Department of Environmental
sign this form for OLS
Protection), and that I am aware that
DFW
I. Name
2 Authorized Signature
VP
3. Position7Tille
4. Data (MM/DDIYYYY)
,eF 762-31f90
AIR SAFE.ING
5. liompoone
6. Representing
23 PJYCHWOCID DR
111-11 F PON
-
7. Address
B Cnylrown
MA
- -
('11160
9. State
10 Zip Code
I oft I 1/[ 5/2016 3:23 PN
AO Od - Asbestos Removal Nodilication form ANF-001- Transaellon...
httpssr/eciep,dep.nrlss,gov(WebPorms/Asbestos/l3 W PANP001.aspx
notification purposes this permit application or nobhoation
shall not be Deemed vano unless
payment of the applicable fee is made"
ni' I I'I> 2016 3:>3 PM
Jane Doucette
From:
Sent:
To:
Subject:
Attachments:
Dear Mansfield Board of Health,
AIRSAFE INC <airsafeinc@airsafeinc.com>
Tuesday, November 15, 2016 3:49 PM
Jane Doucette
Asbestos Notification Form
ANF Steale, Mansfield.pdf
I have attached for your convenience the asbestos notification form filed with the DEP for an asbestos removal job Air
Safe Inc. is contracted to perform November 16-18, 2016 at the residence of a George Steale, located at 90 Pratt Street
in Mansfield. The attached form is a revision in which we modified the dates; it is not the original, full-length form. If you
would like or require the full-length form, or if you have any questions or concerns, please do not hesitate to contact us.
Thank you,
David Walsh
Air Safe, Inc.
(978)339-5361
a irsafeincCo)ai rsafei nc.com