HomeMy WebLinkAboutSo. Main St. #140 - 8/23/2003Commonwealth of Massachusetts ■
(100000680
Asbestos Notification Form ANF-001 Decal Number
Affix Asbestos
Notification Decal
Here
Important:
A Asbestos Abatement Description
p
Whennfilling out
forms the
computer, use
1. a. Is this facility fee exempt - city, town, district, municipal
housing authority, owner -occupied
only the tab key
residence of four units or less? ❑✓ Yes ❑ No
to move your
cursor -do not
use the return
b. Provide blanket decal number if applicable:
Blanket �ecai Number
key.
2. Facility Location:
FORTE RESIDENCE_
140 S MAIN'rSTREET
a Name of Facility
MANSFIELD I IMA
b. Street Address
02048 __ w�
c Cityfrown d_-State
e. Zip Code f. Telephone Number
INSTRUCTIONS 3. Worksite Location:
1. All sections of this OUTSIDE=� I
form must be a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
completed in order
to comply with 4.
Is the facility occupied? [] Yes [] No
DEP notification
requirements of 310
CMR 7.15 5.
Asbestos Contractor:
and the Division
of Occupational
PETER GRI FE_R ENTERPRISES, INC.
Safety (DOS)
a. Name
notification
requirements of 453
CRANSTON 02 910
CMR 6.12
c. City/Town d. Zip Code
6 IPETER D GREIFER
7.
8. i..... ----
a. Name of Asbestos Anal ical Lab
0 9 08121/2003
a. Project Start Date mm/dd/ _ ____
N c. Work hours Mon -Fri.
o 10. a. What type of project is this?
o ❑ Demolition C1 Renovation
Repair ❑ Other, please specify:
780 RESERVOIR AVE, #194
b. Address
4019464506
e. Telephone Number
g. Contract Type: [V] Written ❑ Verbal
b. Describe
11. a. Check abatement procedures:
o ❑ Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
LL ❑ Cleanup tv] Other, specify: (SHINGLE REMOVAL
❑ Full containment b. Describe
z
12. Is the job being conducted: ❑ Indoors? Z✓ Outdoors?
0 anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 0
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
100000660
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
enca sulated: __— 2_- _
000
a. Total pipes or ducts (linear ft) 5-Tofal o(i-ier su aces square
c. Boiler, breaching, duct, tank
C�
surface coatings
Lin. ft.
Sq. ft.
d. Insulating cement
Lin. ft.
e. Corrugated or layered paper
l
pipe insulation
Lin. ft.
Sq. ft_._l
f. Trowel/Sprayer coatings
Lin. ft.
g. Spray -on fireproofing
Lin. ft.
--
Sq. ft.
h. Transits board, wall board--�
Lin. ft.
l
i. Cloths, woven fabrics
Lin. t.
—__�
S . ft.
i. Other, please specify:
k. Thermal, solid core pipe
CEMENTSHINGLE
insulation
Lin. ft.
Ss. ft.
I. Specify
14. Describe the decontamination system(s) to be used:
N/A
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
ILABELED BAGS WITH BURLAP LINER I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency
a� f DEP Official
—1
b. Title
Ld.
c. Date (mm/dd/yyyy) of Authorization
DEP Waiver #
e. Name of DOS Official
t. DOS Official Title
g. Dale (mm/dd/yyyy) of Authorization
h. DOS Waiver #
17. Do prevailing wage rates as per
M.G.L. c. 149, § 26,
27 or 27A-F apply to this project? Yes [j No
B. Facility Description
RESIDENTIAL
1. Current or prior use of facility:
2. Is the facility owner -occupied residential with 4 units or less? g Yes ❑ No
3 �JOE FORTE
a Facility Owne
c. City/Town
4. N/A----
a. Name of Factl
■ anf001 ap.doc • 10/02
Asbestos Notification Form • Page 2 of 3 0
FLCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
M
O
0
N
0
0
0
LL
Z
Q
L100000680
Decal Number
B. Facility Description (cont.)
5. ==— --
a. Name of General Contractor b. Address
c. City/Town _ d. Zip Code— e. Telephone Number area code and
BEACON MUTUAL 0000007296 M
f. Contractor's Worker's Comp. Insurer q. Policy Number h. E>
6. What is the size of this facility? [750 _] r3
a. Square Feet b. Nt
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
ASBESTOS CONTRACTOR _ �J
a. Name of Trans2orter
..--� E_J
c. City/town d. Zip Code
b. Address
—�
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
SERVICE TRANSPORT _ 28 PRIVILEGE STREET
me a. Naof Trans orter _ b. Address _
WOONSOCKET, RI 02895
3.
4. IBFI IMPERIAL LANDFILL
a. Final Disposal Site Location Name
[PO BOX 47-11 BOGGS ROAD —�
c. Finnalil Disposal Site Address
PA 15126 _j
e. State f. Zip Code
D. Certification
The undersigned hereby slates, under the
penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos, 453 CMR 6.00 and
310 CMR 7.15, and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
Id. Cityfrown
L�
g. Telephone Number
I PETER GREIFER I
(401) 946-4506 JJ CONTRACTOR 1
e. Telephone Number f. Reresentinq _
1780 RESERVOIR AVE, #194
g. Address __ __ _
CRANSTON, RI _ 02910
h. City/Town i. Zip Code
GoW
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