HomeMy WebLinkAboutWarren Ave. #42 - 7/27/2006LlCommonwealth of Massachusetts ■
100035314
Asbestos Notification Form ANF-001 Decal Number
Important:
When filling out
fors on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
A. Asbestos Abatement Description
1. a. Is this facility fee exempt - city, town, district, municipal housing authority,
residence of four units or less? 1,11 Yes 1 No
b. Provide blanket decal number if applicable:
2. Facility Location
!HERNANDEZ
a. Name of Facility
!Mansfield IMA
c. CityfTown d. State
3. Worksite Location:
1. All sections of this ;BASEMENT
form must be a. Building NamelBuilding Location b. Building # c. Wing d. Floor e. Room
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
I,
Blanket Decal Number
142 WARREN AVENUE
b. Street Address
102048
e. Zip Code I. Telephone Number
Is the facility occupied? ❑✓ Yes ❑ No
Asbestos Contractor:
NEW ENGLAND SURFACE MAINTENANCE j I850 WASHINGTON STREET
a. Name b. Address
IWEYMOUTH 02189 [7813372117
c.City/Town d , d. Z� s. Telephone Number _..
AC000cen g. Contract Type: ❑ Written ❑ Verbal
I. DOS License Number .,
6 iPAUL W BROWN
a. Name of On -Site Su.
7 S.COHENCOHEN
8.
9.
_— 0
�
I
I
N
IENVIROTET LABORATORY I
0712712006
7.5
cc—w
0 10. a. What type of project is this?
o IFi Demolition ❑✓ Renovation
❑ Repair ❑ Other, please specify:
11.
0
LL
z
a. Check abatement procedures
i
b. Describe
h Glove bag ❑ Encapsulation
LE Enclosure ❑ Disposal only
Cleanup ❑ Other, specify:
✓! Full containment b. Describe
12. Is the job being conducted: I] Indoors?
anf001 ap.doc • 10102
0 Outdoors?
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Asbestos Notification Form - Page 1 of 3 N
01
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
A. Asbestos Abatement Description
100035394 —�
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
en—
capsulated:
100 —� 30 —�
a. Total pipes or ducts (inear R) TTo a other su aces square Ri
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
1100
pipe insulation
ft.
fLin.
g. Spray -on fireproofing
Lin ft
L Cloths, woven fabrics
Lin
k. Thermal, solid core pipe
insulation
Lin. ft.
30
Sq. R.
d. Insulatingcement
Lin. ft.
—!
Sq. ft.
"
j
I
ft.
f. Trowel/Sprayer coatings
Lin. ft.
R.
rS—q.
h. Transits board, wall board
fSq.
�
Sq. ft.
Lin
qS ft.
S .1L
I. Other, please specify:
Lin. ft
`SI ft.
Sq. ft.
I. Specify
14. Describe the decontamination system(s) to be used:
IAS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
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 r❑ No
B. Facility Description
1. Current or prior use of facility: RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? ❑✓ Yes ❑ No
9
4.
■ anf001ap.doc • 10/02
Asbestos Notification Form • Page a 2
0 Commonwealth 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. Zi Code
i
f. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
C. Asbestos Transportation and Disposal
100035314
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM,LLP
a. Name of Transporter
1c. City/Town d. Zip Code
I I
b. Address
I
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
;RED TECHNOLOGIES I
a. Name of Trans orter b. Address
3.
4. IMINERVA ENTERPRISES INC
e.
D. Certification
44888
f. Zip Code
The undersigned hereby states, 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.
JIM DOYLE
a. Name _
p
c. Position/Title
h. City/rown
i. Zip Code
Go TT TT oop
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