HomeMy WebLinkAboutSo. Main St. #48 - 7/25/2003Commonwealth of MOSSMICIIIJISOM ------..............................
110001005112
Decal Number
— I I I .... ..........
10 Asbestos Notification Form ANF-001
AM AWMGWS
NotiMcaven Decal
Here
- -- --- ----- .......
kapo
When claft fifthly Mk A. Asbestos Abatement Description
fame on the 1 a is this facility fee exempt - city, town, district. municipal housing authority, owner -occupied
cornpunx, use
only the tab key residence of four units or less? :✓.: Yes No . .. .....
to nwe your .. .......
�r - do not b. Provide blanket decal number N altinliesb1s: E . We -
.. UM F*WM
kwy. 2. Facility Location: a Street Tj
Kwon Giffen
.. .. . .. . I. � - . .. ... . I .. b. a
A. , - Ift, ---- ... - .. I.- . .
A Feel
:Mansfield MA !02040 281-7865
. ........ .
CNV/Tmn
I
Worksh a Location:,
iNsTRucilIONS
I ,
1. AM SettlaUs Of this
tam must be
.Some
... . ... .. . .
a, Building NamwFOuUMV Location
6. Buildirig #
"Mpk*ed in mdv
t, WnVV %Ath 4.
is the facility occupied? 'w' Yes
No
DaPnetiffeaden
requlremanO of $10
CMR7.16 S.
Asbestos Contractor:
and am DIV10104,
of owupeoenel
...... —
'AJRSAFE INC
� I - -... . .. .. ...
MORWOOD
:02052
requkentente of 453
GMRS,12
-.d.
Z. $Ubrnk odow
Fum to;
controonw4w of
Ma"Chufflas
Asba,flue PMqf&(e
PO Box 12NOT 6.
t%Q,WMA0211Z-
Met
7
0.
9.
c. winil e. R.osrn
61 ENDICOTT ST
'71111117623390
i;.. ir
AC000444
g. Contract Type: 1, written ,--,Verbal
T.Tjw
... ...... ............... . . .........
6, PRO"
i.
C.... ...... ... ......... ...
�JAJNHE E. AMAYA
. ... ........ • tA686.011147 ... .....
a. Nartlttpt posits
1AMUEL N. CONEN
iiAMM?07
ilENVIROTEST LABORATORY, INC
iAA911110128
b. A10ryjps Mayttpt Lab qd
Lob.
. ....... . .........
. . . ... ........ .. .
b. End DM`M
C,
Was flsue
to. a. What type of project is this?
Demolition Renovation
Repair ."i other, please specify:
1111. a. Check abatement p(OcOdum!
iWi Glove bag Encapsulation
Enclosure Disposal only
J, Cleanup :-'Olher, specify:
Full containment
---- -- --- ------ -
W"
b. 0900FUM
It. Dewhe
12. Is the job being conducted: Indoors? Outdoors?
M anWoPAM - 10102
Asteaka Natification FWM - Page i of 3 N
Commonwealth of massuchussifts
Asbestos Notification Form ANF-001
.Decal Nwriber
A. Asbestos Abetment Description (cont.)
13. Total amount of each type
of Asbestos Containing Materials (ACM) to be removed, enclosed, or
powpWot
.. .. . .......... ..
pip ....M . W . dua . " .0- rm . r
-b Tia-other st . mli� ..(& I qi I Mrs
u. SuRer, brandling, dw. tank
il—,--.-.-; d. kiwWft �t
Sq.
sudam �Onp
9. Cem%aivdw W1"-d Paw
�firlw
: L .......... .. .
Sq, t.
pook"Mm
11. Trmsft b"rd, wag board
Sq.
L claft, Wor" fabdm
Odor, plows SPOCRY:
k Thmem). WN eora P"
F f
14. Describe the decontamination system(s) to be used:
. . .............. ......
!3 CHAMBER
- 1-- -.11 -- I ---- I- - ............ . .... . .... .
15, Describe the conlainatizaton/disposal methods to comply with 30 CMR 7.15 and 453 CMR
;2 PLY POLY BAG VATH LABEL
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16. For Emergency Asbestos Operations, the DEP and DOS of who evaluated the emergency:
---- ..... ........ . ..... ---------
* ...------
..... ......
e. Na4i aDOS I .... f. iI TOW
-----
g. Onto (nwVddVM) of AxAtwfirmUm
A-F P Ac
17. 00 prevailing wage Was as per M.G.L. C. 149, 26, 27 or 27 sp lytothispraj l7j 2Yes,�✓lhlo
B. Facility Description
1. Current or prior use of facility: . . .. ....
1 Is the facility ownor-occupled residential with 4 units or less? Yea 2...; No
. ........ ...... .
!Same
3.
..... . .. .. ..... .... ...
aodi
cily/Tumi --LOT
4. a 0 ..............
U—fter ..... .
d-A, dad& 0 Tewphim MWVW W" .ends'and vxt-,eIffi)
a, ttiryRavn
0 mrom MR.4" - 10/02
Asb"tft NoWflanfim Farm - Page 2 of 3 0
oCommonwealth of MassatChusefte
Asbestos Notification Form ANF-001
B. Facility Description (oont.)
"... ......... .................................. ------
5.
. ... ..... . . .... ....
6. What Is the Bias of this facility?
......... ......
D" Nundser
01 Add"
r- -----
e. Square F"t b, Number of floor¢
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
SERVICE TRANSPORTATION i )POD 12132
" , , rell,
Now: Trander ... . .. .. ...... 1-I 1.141111 k-1 .. .......
Stw0w* musk ZRISTOL .19007 (877) 99"50
outupty with the C. csytyown d. Zip Code e, Telephone Numbat;
som wome
Division 2. Transporter of asbastos-containing waste material from removal/temporary site to final disposal Site;
RMPlationt, 310 . . ..... .....
CUR WRW
............ — ...... .. .......
.... . ......... . . .... .... .. . ...... .. .....
3,
a. Refuse Transfer Station and Ommtor
4. sFI IMPERIAL LANDFILL
a. Final Site Locnoon Natot,
TO BOX 47-11 BOGGS ROAD
;PA
... .. . ...... !IS126
D. certification
The undersigned hereby states. water the
peruftes, of parrury. that he/she has read the
Commonwealth of MaRMIChUMM 11MOU13110M
far the Removal, CWtW~ Or
Encapsulation of Asbestos. 453 GMR 6.00 and
310 CMR 7.115, and ftt the Information
contained in tNs nollf1cation is brus and owed
to the beat of his/her knowledge and belief,
. ... ... ......... ...... .. .... ..
... ..... .. . - . 11 1 1 -1-!
'Allied Waste
.bl
;IMPERIAL
... ... .......
9. Itawians tatonbw
'David F. wa6ii
i.. tft- "M -
Five nt
li?1=003
PKII.ft"d ift"
Y.89.762-33.00
61 Endkmft Streat
. ..... . ............... . .
�Norwmd
102M
h.
Note: Contractor must sign this form for DOS A01WAtion purposes.
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