HomeMy WebLinkAboutPratt St. #256 - 6/4/2018I�
Instructions 1. All
sections of this form
must be completed in
order to comply with
MassDEP notification
requirements of 310
CMR 7.15 and
Department of Labor
Standards (DLS)
notification
requirements of 453
CMR 6A2
MassDEP Use Only
Date Received
2. Submit Original
Form To.
Commonwealth of
Massachusetts
P.O. Box 4062
Boston, MA 02211
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001) '
Asbestos Notification Form
A. Asbestos Abatement Description
1. Facility Location:
MICHAELONEILL
a. Name of Facility
MANSFIELD
c. Ctly/Town
MICHAELONEILL
g. Facility Contact Person Name
Worksite Location:
2. Is the facility occupied? P, a. Yes r b. No
256 PRATTST;:::..
b. Street Address
MA 02048 4014816548
d. State e. Zip Code I. Telephone
100286489
Asbestos Project tt
j— Project Revision
r Project Cancellation
OWNER
h. Facility Contact Person Title
BASEMENT
1. Building Name, wing, Floor, Room, etc.
3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or
owner -occupied residential property of four units or less)? 1v a. Yes i b. No
4. Blanket Permit Project Approval, if applicable:
5. Nan -Traditional Asbestos Abatement Work Practice Approval,
it'applicable:
6. Asbestos Contractor:
AIR SAFE INC
a. Name
Approval ID #
Approval ID #
22 WILLOW STREET
b. Address
CHELSEA MA 02150 9783395361
c. City/Town d. State e. Zip Code I. Telephone
AC000464 h. Contract Type: r' 1. Written r 2. Verbal
g. DLS License #
? SEBASTIAN GAITAN AS000597
a. Name of Contractor's On -Site Supervisor/Foreman b. DLS Certification #
u FRANK N. BALAGTAS
a. Name of Project Monitor
AM000091
b. DLS Certification #
9 FU ENVIRONMENTAL INC AA000144
a. Name of Asbestos Analytical Lab b. DLS Certification #
10.
6/4/2018 6/4/2018
a. Project Start Date (MM/DD/YYYY) b. End Date (MWDD/YYYY)
7AM-5PM NA
c. Work Hours - Monday Through Friday d. Work Hours - Saturday & Sunday
11. What type of project is this?
r a. Demolition r b. Renovation r c. Repair I'-' d. Other - Please Specify:
Revised: 11/13/2013
Page 1
Massachusetts Department of Environmental Protection
L1_
(I00286489
BWP AQ 04 (ANF-001) -
Asbestos Project #
Asbestos Notification Form r" Project Revision
r- Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
rV a. Glove Bag l✓ b. Encapsulation r- c. Enclosure r'- d. Disposal Only r e. Cleanup
(— f. Full Containment r g. Other - Please Spccify:
13. Job is being conducted: r a. Indoors r- b. Outdoors
14 a. Total amount of each type of asbestos Containing materials (ACM) to be removed, enclosed, or
encapsulated:
10
1. Linear Feet (Lin. Ft.) 2. Square Feet (Sq. Ft.)
b. Boiler, Breaching, Duct, c. Transite Pipe
Tank Surface Coatings 1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq, Ft.
d. Pipe Insulation 10 e. Transite Shingles
f. Spray -On Fireproofing
h. Cloths, Woven Fabrics
j. Insulating Cement
1. Lin. Ft. 2. Sq. Ft.
g. Transite Panels
1. Lin. Ft. 2. Sq. Ft.
i. Other -Please Specify:
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft.
1. Lin. Ft. 2. Sq. Ft. 1. Lin. Ft. 2. Sq. Ft.
15. Describe the decontamination system(s) to be used:
THREE CHAMBER DECON
16, Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)
(g)
6 MIL POLY
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:
a. Name of MassDEP Official b. Title of MassDEP Official
c. Date of Authorization (MM/DD/YYYY) d. Waiver #
e. Name of DLS Official
f. Title of DLS Official
g. Date of Authorization (MM/DD/YYYY) h. Waiver#
18. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this r a. Yes r b. No
project?
Revised: 11/13/2013 Page 2 c
Massachusetts Department of Environmental Protection
BWP AQ 04 (ANF-001)
Asbestos Notification Form
B. Facility Description
1. Current or prior use of facility:
RESIDENTIAL
(100286489
Asbestos Project If
L.. Project Revision
f— Project Cancellation
2. Is the facility owner -occupied residential with 4 units or less? r a. Yes r b. No
3 MICHAELONEILL
a. Facility Owner Name
MANSFIELD
a CityfTown
4 MICHAELONFJLL
a. Name of Facility Owners On -Site Manager
MANSFIELD
c. Cityfrown
256 PRATT ST
b. Address
MA 02048 4014816548
d, State e. Zip Code I. Telephone
256 PRATT ST
b. Address
MA 02048 4014816548
d. State e. Zip Code f. Telephone
5 NA NA
a. Name of General Contractor b. ti
NA
c. City/rown
MA 02048 1111111111
d. State e, Zip Code f. Telephone
NA
g. Contractors Workers Compensation Insurer
NA 12/31/2018
h. Policy # i. Expiration Date (MM/DD/YYYY)
6. What is the size of this facility? 1490 2
a. Square Feet b. If of Floors
C. Asbestos Transportation & Disposal
1. Transporter of asbestos -containing waste material from site of generation:
r a. Directly to Landfill or r b. To Temporary Storage Location/Transfer Station
AIR SAFE INC
22 WILLOW ST
c. Name of Transporter
d. Address
Note: Temporary
storage of Asbestos
CHELSEA
MA 02150 9783395361
containing waste
e. City/Town
I. State g. Zip Code h. Telephone
material is only
allowed at the place
of business of a OILS
2. If a temporary storage location/transfer
station is used, list name of transporter of asbestos containing
licensed Asbestos
waste material from temporary storage location/transfer station to final disposal site:
p y g p
contractor or a transfer
station that is
permitted by
SERVICE TRANS GROUP
58 PYLES LANE
MassDEP and
a. Name of Transporter
b. Address
operated in
compliance with Solid
NEW CASTLE
LE 19720 8779999559
Waste Regulations
c. CityfTown
d. Stare e. Zip Code I. Telephone
310 CMR 19,000
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection �1002864-89 J
LFI-\---BWP AQ 04 �ANF-001) Asbestos Project# Asbestos Notification Form (- Projec[Revision
r Project Cancellation
C. Asbestos Transportation & Disposal: (cont.)
3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
Note: Contractor must
sign this form for DLS
notification purposes
AIR SAFE INC
a. Temporary Storage Location Name
CHELSEA
22 WILLOW ST
b. Address
MA 02150 9783395361
d. State e. Zip Code f. Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL MINERVA ENTERPRISES, INC
a. Final Disposal Site Name b. Final Disposal Site Owner Name
8995 MINERVA DRIVE
c. Address
WAYNESBURG
d. City/Town
D. Certification
9 certify that I have personally
examined the foregoing and am
familiar with the information
contained in this document and
all attachments and that, based
on my inquiry of those
individuals immediately
responsible for obtaining the
information, I believe that the
information is true, accurate, and
complete. I am aware that there
are significant penalties for
submitting false information,
including possible fines and
imprisonment. The undersigned
hereby states that I have read the
Commonwealth of
Massachusetts regulations
governing asbestos abatement
(453 CMR 6.00 promulgated by
the Department of Labor
Standards and 310 CMR 7.15
promulgated by the Department
of Environmental Protection),
and that I am aware that this
permit application or notification
shall not be deemed valid
unless payment of the
applicable fee is made."
CH 44688 3308603435
e. State f. Zip Code g. Telephone
1. Name
PRESIDENT
3. Positionrritle
9783395361
5. Telephone
23 WYCHWOOD DRIVE
7. Address
MA
9. Stale
2. Authorized Signature
4. Date (MM/DDIYYYY)
AIR SAFE INC
6. Representing
LITTLEFON
8. City/rown
01460
10. Zip Code
Revised: 11/13/2013 Page 4 of 4