HomeMy WebLinkAboutPratt St. #98 - 3/16/2017AQV14/ASOestoSJcen'tNOT] TICSTIOnroITp/XN -UUI- transaction,,. n11ps2/eoep.oep.mass.guv/Wtororuh-Jm oeNu)5/oWr/crvrvol.asp,
Massachusetts Department of Environmental Protection 100200511
BWP AQ 04 (ANF-001) Asbestos Project#
Asbestos Notification Form
Project Revision
I'L=, Protect Cancellation
A. Asbestos Abatement Description
1. Facility Location:
JULIO AREVALO
a. Name or Facility
MANSFIELD
c. City/Town
JULIA ARFVAI.O
g. Facility Contact Person Name
Worksite Lo afi n'
I98 PRATI STREET
b. Street Address
IMA k048 i7a ;'19 R31fi
d. State e. Zip Code f Telephone
h. Facility Contact Person Title
Instructions 1,Ni C 10 BASL-MENT
sections of this form must r Building Name. Wing, Floor, Room, etc,
be completed in units to
comply with MassDEP 2. Is the facility occupied? tJ a. Yes LI b. No
uotiflcalion requirements
of 3to CW 7.15 and 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner -
Department of Labor occupied residential property of four Units or less)?, RJ a. Yes t-! b. No
Standards (OLS)
noBncation requirements 4. Blanket Permit Project Approval, if applicable:
or 453 CWYi 6,12 Approval ID #
5. Non -Traditional Asbestos Abatement Work Practice Approval, if applicable:
MassDEP Use Only Approval ID #
6. Asbestos Contractor:
Date Received AIR SAFE INC - j22 WILt.OW STREET
a. Name b. Address
CHELSEA MA W150 976-339-5161
2. Submit Original c City/Town d. State e. Zip Code I. Telephone
Form ToACOOO404 fa 1. Wntten U 2 Verbal
Commonwealth o/ - - - --- - h. Contract Typo
Massachusetts P.O. TL DES License #
Box 4062 Boston, MA SEBASn IAN (.-,At LAN - A6000507 -
02211 a. Name of Contractor's On -Site Supervisor/Foreman b. DES Codification #
9, PAUL NEVINS ANi900334.
a. Name of Project Monitor b, DLS Codification #
g, EMSLANALYTICAL INC
iAA000188
a. Name of Asbestos Analytical Lab
Is DES Certification #
10, 03+I6/2017
03176/2.01: ,
a. Project Start Date (MM/DD/YYYY)
or End Date (MM/DDrYYYY)
7AM - SPM
'. 'NA
c. Work Hours Monday Through Friday
it Work Hours - Saturday & Sunday
11. What type of project is this?
I I a. Demolition [',l Its Renovation LJ c. Repay ❑ d. Other - Please Specify: I
12, Abatement procedures (check all that apply):
CI li a. Glove Bag El l b. Encapsulation 11 c, Enclosure I d, Disposal only [7 1 e. Cleanup 1,7 1. Full Containment
❑ g. Other -Please Specify:+
1 44 3L1/2017 4:13 PNt
A 04 -Asbestos Removal Notification Form ANF-001- Transaction..,
httpsJ/edep.dep.inass.gov/WobFonns/Asbestos/BWPANFOO
Laspx
B. Facility Description
1. Current or prior use of facility: RFSRnEN
Iml
2. Is the facility owner -occupied residential
with 4 units
of less?
NI ! a. Yesis to No
3, JULIO AREVALO
ria PRATT SIRFF.i .._. ..i
a. Facility Owner Name
b. Atltlress
MANSFIELO
MA
07048,.
774-219A316 i
a City/Town
d. Stale
e, Zip Code
f. Telephone
4. JULIA AREVALO
' JB PRATT STREET
a. Name of Facility Owner's On -Site Manager
b. Address
'..MANSFIELD
MA
i '.:02048
774-219.8310
C. City/Town
d. Stale
e. Zip Code
L Telephone
6, NA
'NA
a. Name of General Contractor
b. Address
NA
MA
:.02048
lit-1711711 1
c Citynown
d. Slate
e. Zip Code
f. Telephone
NA
',..
g. Contractor's Worker's Compensation Insurer
NA
1213112017
IT, Polley q
I. Expiration Date (MMI)D/YYYY)
6. What is the size of this facility?
1614
2
a. Square Feet
b, N of Floors
C. Asbestos Transportation & Disposal
1. Transporter of asbestos -containing waste material from site of generation:
!_111 a, Directly to Landfill or fR b. To Temporary Storage Location/Transfer Station
.AIR SAFE INC
'i '7.2 WILLOW STREET
c. Name of Transporter
d. Address
CHELSEA-
=iMA 02150 978339-5367
e. City/Town
L State g, -Lip Code T. Telephone
2. If a temporary storage location/transfer station is used, list name of transporter of asbestos
containing waste material from temporary storage location/transfer station to final disposal site:
SERVICE TRANS GROUP 58 PYLES LANE
a Name of Transporter to Address
NEWCASTLE 'OE + �10720 ; �007.9D9.9550
c Cityrrown it State a Zip Code f, Telephone
3. Name and address of temporary storage locationitransfer station for the asbestos containing waste
material:
AIR SAFE INC
� 22 WILLOW ST
a Temporary Storage Location Name
b Address
-. ..
CHCLSEA
r ... _.. .. ..,_.. ... _... ._.
iMA t (02150 .970-33g-5361
a Cityrrown
d. State e. Zip Code f. 'Telephone
4. Name and location of final disposal site (asbestos landfill):
--MINERVA MINERVA ENTERPRISES, INC
a. Final Disposal Site Name b. Final Disposal Site Owner Name
'i9000 MINERVA RD
c. Address
? of4 3/3/20174:13 PM
AQ 04 - Asbestos Removal Notification Form ANF-001- Transaction... hops://edep.(Iep.nlass.gov/WcbForms/Asbestos/F3W PANFOOLaspz
of Asbestos containing
'WAYNESBURG
OH -44666 330-66G3435
haste material is only
it City/Town
e. Slate f ZipCode I). Telephone
ailowetl at the place of
-
13. Job is being conducted: &)
a. Indoors ;;7'., b. Outdoors
business of 019
fceniied Asbastos
14 a. Total amount of each type of
asbestos Containing materials (ACM) to be removed, enclosed, or
canmcter a a lmnsfur
encapsulated:
station that is porn hied by ' 100 _... _...
':. i ... .. _.... _.-. _..
MossDEP and operated in
1. Linear Feet (Lin. Ft.)
2. Square Feet (Sq. FL)
compliance with Solid
Waste Regulations 3t0
b. Boiler, Breaching, Duct, Tank
c. Transits Pipe
CMR 1gW0
Surface Coatings 1. Lin. Ft
2. Sq. FL '1. Lin. Ft. 2, Sq. Ft.
d. Pipe Insulation 160
- e. Transits Shingles L
1 Lnt. FL
2 Sq Ft, t, Lin. FL P. Sq. FL
Note! Contractor must
Sign this form for OL$
notification Purposes
f. Spfay-On Fireproofing 9. Transile Panels
1 Lin, FI. 2. sq. rt. 1. Lin Ft 2. Sq. Ft
h. Cloths, Woven Fabrics I. Other- Please Specify!
1. Lis Ft. 2. Sq, Ft.
j. Insulating Cement
1 Lin FL 2. Sq. Ft. - 1. Lin. Ft, 2, Sq. Ft
15. Describe the decontamination system($) to be used:
THREE CIIAN113CP DE.CON
16, Describe the containerization/disposal methods to comply with 310 CMR 7,15 and 453 CMR
6.14(2)(g):
6 MII POLY _.. _. _... _.
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the
emergency:
a. Name of MassDEP Official
b. Title of MassDEP Offioial
C. Date of Authorization (MM/DDIYYYY)
d Waiver q
e Name of DLS Official
f. Title of DLS Official
g. Date of Authorization (MMIDDIYYYY)
h, Waiver t1
18. Do prevailing wage rates as per M.G.L, c. 149, § 26, 27 or 27A—F apply to this Li a. Yes rj b. No
D. Certification
"I certify that I have personally examined
DEW
the foregoing and am familiar with the
1. Name
2 Aulhonzed Signature
information contained in this document
yr
and all attachments and thatbased on
-
my Inquiry of Ihose individuals
3. Posltion/Title
4. Date (MMIDD7YYYY)
immediately responsible for obtaining
',976-339-5361.
AIR SAFE, INC
the information, I believe (hat the
6. Telephone
6. Representing
Informa(ion is Ime, accurate, and
',23 WYCHW000 DRIVE
: LITTLETON
complete, I am aware that there are
7. Address
6. Ciryrrown
significant penalties for submitting false
information, including possible fines and
IMA
01460
imprisonment. The undersigned hereby
9, State
10. Zip Code
3 ol'4 3/3/2017 4:13 I'M