HomeMy WebLinkAboutWest St. #116 - 7/27/2010C3
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INSTRUCTIONS
1. All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
100109727
Decal Number
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: t Blanket Decal Number
2. Facility Location
,HOUSE
1161NEST ST
'
Facile
a. -Name of_h'
__.._
Mansfield _-
c. Citylrown
-- �
b. Street Address
AMA
_ 02048
_,
d. State e. Zip Code
5083415843 i
f Telephone Number
3. Worksite Location:
HOUSE
.__. _.._ -_..
a. Building Name/Binding Location
_�
b. Building # c. Wing
BASEMENT. _ r
d Floor a Room -
Is the facility occupied? 'Vl Yes ( No
Asbestos Contractor:
.__. ......____I
163 RICE AVENUE .
AERO TEC ENVIRONMENTAL _
a. Name -
b Address
NORTHBOROUGH [01532 19783759534
._.. —
:. C1 Rown
__ ty - _ _ d Zip Code e. Telephone Number
g. Contract Type: [✓! Written L._ I Verbal
6 GREGORY W HARDING-.;
a: Name of On -Site Supervisor/Foreman
7 IJOHN BACHAND
a. Name of Project Monitor
8 .NORTHEAST ENVIRONMENTAL
a. Name of Asbestos Analytical Lab
7/26/2010
9' a. Protect Start.Date (mm/ddlyyyyt
7AM 7PM
--
c. Work hours Men-Fn
10. a. What type of project is this?
L. j Demolition ; Renovation
✓] Repair j_J Other, please specify:
11. a. Check abatement procedures:
Glove bag l 1 Encapsulation
Enclosure Disposal only
Cleanup [_i Other, specify:
Iil Full containment
12. Is the job being conducted: Wl Indoors? !,, 1 Outdoors?
M anf00l ap.doc • 10/02 Asbestos Notification Form • Page i of 3
Commonwealth of Massachusetts
I] Asbestos Notification Form ANF-001
A. Asbestos Abatement Description (cont.)
-- -
1100109727 -�
Decal Number
13, Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated;
--
115.
a. Total pipes or ducts (Imear ft) b. Total other surfaces (square it)
c. Boiler, breaching, duct, lank
surface coatings
e. Corrugated or layered paper
pipe Insulation
g. Spray -on fireproofing
I. Cloths, woven fabrics
k. Thermal, solid core pipe
insulation
14. Describe the decontamination system(s) to be used:
3 CHAMBER WASH BUCKET
d. insulating cement
. --- -----
Lin. ft.
f. Trowel/Sprayer coatings
Lin. ft.
h. Transite, board, wall board
I i
I" ---------..�
Lin. ft.
I. Other, please specify'
- .-.---.-i
I Specify
-_---
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (g):
I6_MILL DOUBLE BAG---_-..
16-
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A-F apply to this project? [ ! Yes I.✓i No
B. Facility Description
I. Current or prior use of facility: (HOUSE T
2. Is the facility owner -occupied residential with 4 units or less? !✓I Yes i__. No
--
- ---- --
3 SUZAN WENWORTH I i
-- -- --- - -- - - a. Facility Owner Name b. Atltlress
.._ -. ---- - a- G. Cdy/Town ,d Zip Code - e Telephone Number (area codee and extension)
4 t-
-- ---- - - a. Name of Facility Owner's On Site Manager b On -Site Manager Address
c. Cily(fown d. Zip Code e. Telephone Number (area code and extension)
® anf001 ap.doc • 10102 Asbestos Notification Form • Page 2 of 3
Commonwealth of Massachusetts
LiAsbestos Notification Form ANF-001
B. Facility Description (cont.)
5. a Name of General Contractor
i
a City/Town - d Zip Code_
f. Contractors Worker's Comp. Insurer
6. What is the size of this facility? -------- --
a. Square
C. Asbestos Transportation and Disposal
1100109727
-- ---
Decal Number
code and extension)_ _
h. Exp Date (mm/dd/yyyy)-
L
b. Number of floors
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
'iAERO TEC
Note: Transfer a. Name of Transporter - b Address
Stations must [ i t (
comply with the c. City[Town d. Zip Code e. Telephone Number
Solid Waste
Division 2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
Regulations 310 __-_._ _..._._--... __._—...
CMR 19.000 ATL ( ---.-__.._.._..________.'
a, Name of Transporter b. Address
1..___--- . _ ....__ .-
a-CItyffown___ d Zip Code, e. Telephone Number
t-- ------- ___.__..._—
3.
a. Refuse Transfer Station and Owner b. Address
,_c, CRy/Town d Zip Code e Telephone Number -
4. jMINERVA ENTERPRISES INC
a, Final Disposal Site Location Name b Final Disposal Site location Owners Name
9000 MINERVA ROAD 'WAYNESBURG
__ - __. _ --- _
c,Final Disyosal Ste Address _ d City/Town _ - _, _ ---------
.OH
I 14 688
-- - — ----
e. State I. Zip Code g. Telephone Number
M
0
D. Certification
The undersigned hereby states, under the IGREGORY HARDING I !Gregory Harding
penalties of er'ur , that he/she has read the -.-__ - �- _ -- `-`
p p 1 Y a Name _ b Authorized Skinature
o Commonwealth of Massachusetts regulations iOWNER �7/1512010
for the Removal, Containment or -- -- ---- ----- --`
c. Posdionrrille __ -- d Date_(mm/dd/yyyy)__
Encapsulation of Asbestos, 453 CMR 6.00 and '9783759534 l j
310 CMR 7.15, and that the information L.—
contained in this notification is true and correct e. Telephone- Number _ f Representing__.
to the best of his/her knowledge and belief. 1163 RICE AVE
o q Address
a �NORTHBORO_
h. Cityrrown i. Zip Code
Z
Q
® anf001ap.doc • 10/02 Asbestos Nofification Form • Page 3 of 3