HomeMy WebLinkAboutSchool St. #229-243 - 10/29/2014Instructions 1. All
sections of this forth
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 6.12
Commonwealth of Massachusetts,
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
1. Facility Location:
VACANTRESIDENCE
Name of Facility
MANSFIELD MA
Cityfrown State
JACQUELINE SEITERDAHL
Facility Contact Person Name
Worksite Location:
2. Is the facility occupied? i- Yes r No
10020 2250
Asbestos Project #
r Project Revision
[, Project Cancellation
02048 63025377--------•--------
ZipCode Telephone
ENVIRONMENTAL SPECIALIST
Facility Contact Person Titte
BS1VTr&2ND FL BATH
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)? r Yes G No
MassDEP Use Only 4. Blanket Permit Project Approval, if applicable:
Date Received Approval
5. Non -Traditional Asbestos Abatement Work Practice Approval,
2. Submit Originalif applicable: Approval ID#
Form To:
Commonwealth of 6. Asbestos Contractor:
Massachusetts DEC-TAMCORPORAnON 50 CONCORD STREET
Asbestos Program
P.O. Box 120087 Name Address
Boston, MA 02112- NORTH READING MA 01864 9784702860
0067 City?own State Zip Code Telephone
AC000035 Contract Type: rT Written ❑ Verbal
DLS License #
7, GEORGEA. PAGE
Name of Contractor's On -Site Supewisor/Foreman
8. SMITH&WESSELASSOCIATES INC
AS071933
DLS Certification #
AA000161
Name of Project Monitor
DLS Certification #
9, SMITH&WESSEL ASSOCIATES INC
AA000161
Name of Asbestos Analytical Lab
DLS Certification#
10. 10/2712014
10/2912014
Project Start Dale (MMIDDIYYYY)
End Date (MM/DDNYYY)
7A-330P
N/A
Work Hours - Monday Thmugh Friday Work Hours - Saturday &
11. What type of project is this?
r Demolition r Renovation ❑ Repair ❑ Other - Please Specify:
lol0 /
Revised: 11/13/2013
Commonwealth of Massachusetts 100209260
Asbestos Notification Form ANF-001 Asbestos Project #
L- Project Revision
A 7 Project Cancellation
A. Asbestos Abatement Description: (cont.)
12. Abatement procedures (check all that apply):
[✓I Glove Bag ❑ Encapsulation ❑ Enclosure [ Disposal Only r Cleanup r Full Containment
[7 Other - Please Specify:
13. Job is being conducted: r. Indoors
[ Outdoors
14. Total amount of each type of asbestos Containing
materials (ACM) to be removed, enclosed, or
encapsulated:
120
1240
Linear Feet (Lin. Ft.)
Square Feet (Sq. Ft.)
Boiler, Breaching, Duct,
Transite Pipe
Tank Surface Coatings Lin. Ft Sq. Ft
Lin. Ft Sq. Ft
Pipe Insulation 120
Transite Shingles
Spray -On Fireproofing
Cloths, Woven Fabrics
Insulating Cement
Lin. Ft Sq. Ft
Lin. FL Sq. Ft
Lin. Ft. Sq. Ft
Lin. FL Sq. Ft
15. Describe the decontamination system(s) to be used:
TNREESTAGE
Transite Panels
Other - Please Specify:
57T PT. ME
Lin. Ft Sq. Ft
Lin. Ft Sq. Ft
1240
Lin. Ft. Sq. R.
16. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2)(g):
MATERIALS WILL BE WETTED AND PLACED IN DOUBLE BAGS AND LABELED FOR TRANSPORTATION
17. For Emergency Asbestos Operations, the MassDEP and DLS officials who evaluated the emergency:
Name of MassDEP Official
Title of MassDEP Official
Date of Authorizalion(MMIDD/YYYY) Walver#
Name of DLS Official
Title of DL5 Official
Date of Authorization(MMIDDfYYYY) Waiver#
18. Do prevailing wage rates as per M.G.L. c. 149, § 26,27 or 27A—F apply to this (- yes r.. No
project?
Revised: 11/13/2013 Page 2 of 7
_ Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
ri
i
B. Facility Description
1. Current or prior use of facility: RESIDENCE
100209250
Asbestos Project #
r Project Revision
r Project Cancellation
2. Is the facility owner -occupied residential with 4 units or less? r Yes �i No
3. BRIDGESTONE RETAIL OPERAnONS LLC
Facility Owner Name
BLOOMINGDALE It.
Cily/rown
State
4. JACQUELINE SETTERDAHL
Name of Facility Owner's On -Site Manager
BLOOMINGDALE L
Cityrrown
State
333 EAST LAKE STREET
Address
60108 6302599377
Zip Code Telephone
333 EAST LAKE STREET
Address
60108 6302599377
Zip Code Telephone
5. NIA
NIA
Name of General Contractor
Address
NIA
MA 01864
9784702860
City/rown
State Zip Code
Telephone
Note: Temporary
GREAT DIVIDE INSURANCE CO
storage of Asbestos
containing waste
Contractor's Workers Compensation Insurer
material is only
WCA153726612
12/28/2014
allowed at the place
Policy#
Expiration Date (MM/DDNYYY)
of business of a DLS
licensed Asbestos
6. What is the size of this facility?
3000
3
contractor or a transfer
station that is
permitted by
Square Feet
# of Floors
M and
C. Asbestos Transportation & Disposal
operatedcrated in
compliance with Solid
Waste Regulations 1. Transporter of asbestos -containing waste material from site of generation
310 CMR 19.000
r Directly to Landfill or r To Temporary Storage Location/Transfer Station
SERMCETRANSPORT
Name of Transporter
NEWCASTLE CE
City/Town
State
58 PYLES LANE
Address
19720 8779999569
Zip Code 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:
Name of Transporter
Address
City/rown State Zip Code Telephone
Revised: 11/13/2013 Page 3 of 4
Commonwealth of Massachusetts 100209250�
FL-
1Asbestos Notification Form ANF-001 Asbestos Project #
❑ Project Revision
I Project Cancellation
signNote: is farm for must C. Asbestos Transportation & Disposal: coat.
sign this farm for DLS p P (cont.)
notifIcation purposes 3. Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
Temporary Storage Location Name
City/rown
Address
State Zip Code Telephone
4. Name and location of final disposal site (asbestos landfill):
MINERVA LANDFILL CIO RANDY BRIDGES
Final Disposal Site Name Final Disposal Site Owner Name
9000 MINERVA ROAD
Address
WAYNESBURG
City/Town
A Certification
"I certify that I have personally
examined the foregoing and am
familiar with the information
contained in this document and
ail 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 8779999569
State Zip Code Telephone
MIIFMORRIS MIIEMORRIS
Name
SALES
Posigon/rdle
9784702860
Telephone
50 CONCORD STREET
Address
MA
State
Authorized Signature
10/10/2014
Date (MM/DDIYYYY)
DEC -TAM
Representing
NORTH READING
City/rown
01864
Zip Code
Revised: 11/13/2013 Page 4 of 4