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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
100048387
Decal Number
A. Asbestos Abatement Description
1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? ❑✓ Yes I❑ No
b. Provide blanket decal number If applicable: Blanket Decal Number
R1
INSTRUCTIONS 3.
Facility Location
FRECHETTE
1
1193 SPRING ST,
a. Name of Facility
b. Street Address
Mansfield
!MA 102048
c. City/Town
d. State e. Zip Code f. Telephone Number
Worksite Location
1. All sections of this BATHROOM I I I 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:
Division
NEW ENGLAND SURFACE
MAINTENANCE
of Occupational
of Occupational
Safely (DOS)
a. Name
notification
!WEYMOUTH
j 102189
requirements of 453
CMR 6.12
c. Ci (Town
d. Zip Code
.
Annnn1QR _.
..
6 !JOHN S BUTTS JR
a. Name of On -Site Sups7.
S.COHEN
8. 1ENVIROTEST LABS
a. Name of Asbestos Anal,
0 9. [12108/2006
a. Pro ect Start Date mm
84
c. Work hours Mon -Fri.
o 10. a. What type of project is this?
o Demolition ❑ Renovation
Repair ❑ Other, please specify: b. Describe
11. a. Check abatement procedures:
o ❑ Glove bag ❑ Encapsulation
o ❑ Enclosure ❑ Disposal only
a ❑ Cleanup ❑ Other, specify:
10, Full containment b. Describe
z
C 12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors? cm
anf001 ap.doc • 10102 Asbestos Notification Form -Page 1 of 3,10,
850 WASHINGTON STREET
b. Address
78 331 72117
e. Telephone Number
g. Contract Type: ❑ Written ❑ Verbal
NOV
ILICommonwealth of Massachusetts
Asbestos Notification Form ANF-001
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A. Asbestos Abatement Description (cont.)
100048387 —�
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
(o --- 1 70
a. Total pipes or ducts (linear ft) e. i otal other surfaces square
c. Boiler, breaching, duct, tank
surface coatings Lin. ft.
e. Corrugated or layered paper
I__j
pipe insulation
Lin. ft.
g. Spray -on fireproofing
I
Lin. ft.
i. Cloths, woven fabrics
Lin. ft.
k. Thermal, solid core pipe
j
insulation
Lin. ft.
14. Describe the decontamination system(s) to be used:
AS REQUIRED
7-7
d. Insulating cement
Lin. ft.
I. Trowel/Sprayer coatings
Lin, ft.
h. Transits board, wall board
i. Other, please specify:
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
i[:]
REQUIRED
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
D. Title
d. DEP Waiver#
. DOS Official Title
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 ✓❑ No
R. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No
3.
4.
■ anf001ap.doc • 10102
Asbestos Notification Form • Pa a 2�
LlCommonwealth of Massachusetts
Asbestos Notification Form ANF-001
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
B. Facility Description (cont.)
5' a. Name of General Contractor
c. City/Town d. Zip Code
i
f. Contractors Worker's Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
100048387
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
,NESM LLP
a. Name of Trans orte. prb. Address
c. City/Town d. Zip Code e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
!RED TECHNOLOGIES
a. Name of Transporter
c. City/Town d. Zip Code
3.
a. Refuse Transfer Station and Owner
4, IMINERVA ENTERPRISES INC
9000 MINERVA ROAD
c. Final Disposal Site Address
OH 44588
e. State f. Zip Code
D. Certification
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
forthe 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 coned
to the best of his/her knowledge and belief.
E anf001 ap.doc - 10/02
KEN FURTNEY
a. Name
b. Authorized Signature
11/27/2006
c. Position/Title
d. Date mm/dd/
e. Telephone Number
f. Representing
.. Address
h. Cityfrown _
i. Zip Code
Asbestos Notification Form - Page 3 of 3