HomeMy WebLinkAboutWest St. #575 - 6/17/2005Commonwealth of Massachusetts ■
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Asbestos Notification Form ANF-001
Decal Number
ant:
p A. Asbestos Abatement Description
Whenfilling out
When f
forms on 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 Z No
to move your
cursor- do not
b. Provide blanket decal number if applicable:
Blanket Decal Number
use the return
key.
2.
Facility Location:
COMMERCIAL BUILDING
575 WEST STREET
a. Name of Facility b. Street Address
MANSFIELD —I IMA 102048
a CilyfTown - d. State
e. Zip Code f. Telephone Number
INSTRUCTIONS
3.
Worksite Location:
1. All sections of this
1ST FLOOR OFFICE AREA
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
NORTHEAST REMEDIATION
253 LOW STREET SUITE 224
Safety (DOS)
a. Name
b. Address
notrequirements
requirements of 453
NEWBURYPORT 01950 6173899188
CMR 6.12
. Cit !town d. Zi Code
e. Telephone Number
1160003
A6000392
g. Contract Type: ❑✓ Written ❑ Verbal
f. DOS License Number
MICHAEL MARX
REIT MANAGEMENT & RESEARCH REP.
h. Facilit Contact Person
1. Contact Person's Title
EDWIN ALMONTE
AS033135
6'
a. Name of On -Site Supervisor/Foreman
b. Supervisor/Foreman DOS Certification Number
7
ENVIRONMENTAL HEALTH & ENGINEERIN
N/A
a. Name of Pro'ecl Monitor
b. Project Monitor DOS Certification Number
8
YEE CONSULTING GROUP
IAA000145
a. Name of Asbestos Analytical Lab
b. Asbestos Analytical Lab DOS Certification Number
0
9
06/14/2005
06117/2005
a. Project Start Date mm/dd/
b. End Date mm/ddl
0
7AM-3PM
N/A
N
c. Work hours Mon -Fri.
d. Work hours Sal -Sun.
0
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
0
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
LL
❑✓ Full containment
b. Describe
z
12.
Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
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Asbestos Notification Form • Page 1 of 3 ■
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Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
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0
0
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LL
A. Asbestos Abatement Description (cont.)
100018086
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
0 12875
a. Total pipes or ducts linear ft) o a other su aces square t
d. Insulating cement Lin
f. Trowel/Sprayer coatings Lin
h. Transits board, wall board
c. Boiler, breaching, duct, tank
u
surface coatings
Lin. ft.
e. Corrugated or layered paper
I
pipe insulation
Lines. ftt.`�II
l
g. Spray -on fireproofing
Lin. ft
i. Cloths, woven fabrics
Lin
k. Thermal, solid core pipe
insulation
Lin. ft.
I. Other, please specify:
VAT/CARP/MAST
14. Describe the decontamination system(s) to be used:
THREE -CHAMBERED DECONTANMINATION FACILITY W/ SHOWER
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
IACM WILL BE WET (HAND TO BAG). ACM WILL BE LABELED. PACKAGED & TRANSPORTED.I
For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency
b. Title
d. DEP Waiver #
. DOS O wial 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
B. Facility Description
1. Current or prior use of facility:
COMMERCIAL BUILDIING
2. Is the facility owner -occupied residential with 4 units or less? ❑ Yes ❑✓ No
REIT MANAGEMENT & RESEARCH LLC 9 GALEN STREET, SUITE #400
3' a. Facility Owner Name b. Address
WATERTOWN 1 102472 1 1617-928-1300
4 IMICHAEL MARX c I 19 GALEN STREET, SUITE #400
e.
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Commonwealth of Massachusetts
by
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
N/A
5' a. Name of General Contractor
I
c. City/Town d. Zi Code
I. Contractors Worker's Comp. Insurer
6. What is the size of this facility?
100018086
Decal Number
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NORTHEAST REMEDIATION 253 LOW STREET, SUITE #224
Note: Transfer a. Name of Transporter b. Address
Stations must NEWBURYPORT —� 01950 (617) 389.9188
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 ISERVICE TRANSPORT GROUP 58 PYLES LANE
a. Name of Transporter b. Address
NEW CASTLE, DE 19720 (877) 999-9559
3. (N/A
a. Refuse Transfer Station and C
c. Cil /Town _
4. A & L SALVAGE INC
a. Final Dis osal Site Location N
11225 STATE ROUTE 45
c. Final Disposal Site Address
OH
e. State
D. Certification
44432
f. Zip Code
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth 0f 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.
g. Telephone Number
SARAH MARCONE
a. Name
b. Authorized Signature
PROJECTS COORDINAT
OS131/2005
c. PositionTntle
d. Date mm/dd
(617) 389-9188 1
INER
e. Telephone Number
f. Representing
253 LOW STRET, SUITE #224
Address
NEWBURYPORT
01950
h. City/Town
i. Zip Code
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