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HomeMy WebLinkAboutWest St. #1680 - 11/15/2013NOV-20-2013 16:23 FROM: TO:15082617343 P.2 Massachusetts Department of Environmental Protection iooisass3 "` Bureau of Waste Prevention — Air Quality Ducal Number �'�- Project Revision Notification For Asbestos Notification ANF-001 and AQ 00 Important; When tilling out forms on the computer, Mae only the tab key to move your cursor - do not ties the return keeyyl.,4, I INSTRUCTIONS 1. This form Is only available for online filing of projaot data favillona. 2. Enter project decal number. 3. Validate that the project location Is conact for the entered decal. 4. Enter your new Project dates. 5. Certify your nctiflcafion. Submit date changes. A. Facility Location TRAVERS MA 4. State 5 7.Ip Code B. Project Cancelled Q Check here if this project is/was cancelled. C. Project Dates 11/15/2013 11/15/2013 1, original )on 14. IfI 3,—Late_et_R—e_v'laed Start Onto (mm/dd/yyyy) Latest Reviaad End Data (mm/dd/yyyy) D. Revised Project Dates 11,11,1013 9. R$vioed $tort Data (mMddtyyyy) 2, Rovisotl —End Dale We (mmlddryyyy) B. Other Prolect Revisions F. anfO6pdrn.4oc - rov. 2604 NOV-20-2013 16:23 FROM: TO:15082617343 P.3 Commonwealth of Massachusetts 100188563 ti; Asbestos Notification Form ANF-001 Decal Numbee A. is Abatement Description whenrfllrng out roans tthe computer, or, usa 1 e. Is this facility fee exempt - cit district, municipal housing authority,owner-occupied town, g onnlyly the yob key residence of four units or less? Vi Yes ❑ NO to move your cursor -ao not D. rruviue UlmiRal unurl Nun roar It gNylluqula, �Blankef0ewl Number ' use this return key, 2. Facility Location: woRONALD TRAVERS 118eo WEST ST MANSFIEt-D MA 02048 (508) 339.5058 a. ClWrown d. Stale e, Zip Cod® f. Telephone Number IN$TRUOTION$ 3. Worksite Location: 1.A11ee0110neorlhie SAME form must be e. Building Nome/Building Location b- Building 0 c. Wing d. Floor e. Rppm completed In order to comply with 4. pap notlAcatlon requirements of 31a 5 and the Division of Occupallonal Safety (DOS) notification requiremants dr453 AMR $.12 6. 7, ti. 9, Is the facility occupied? ❑✓ Ye$ ❑ NO Asbestos Contractor: 10, a. What type of project is this? ❑ Demolition ❑ Renovation lAf Repair ❑ lather, please specify: 11. a. Check abatement procedures: © Glove bag Encapsulation © Enclosure 8 Disposal only ❑ Cleanup ❑ Other, specify: ❑ Full containment 61 ENDICOTrSTREET b. Address 7817623390 G. Telephone Number g. Contract Type: ® Written ❑ Verbal b. Describe b. Describe 12, Is the job being conducted: ❑ Indoors? ❑ Outdoors? ahf001 ap.doc- 10102 Asbestos Notification Form I Page 1'of 3 NOV-20-2013 16:24 FROM: TO:15082617343 PA Commonwealth of Massachusetts ■ U 100166563 , LdAl Asbestos Notification Form ANF-001 DOW Namber A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or le a lated: ---� 225 W�� I e, Total pipes or duets near 6.-Tover oiFiarauiF+lwalsquareRf d, insulating cement IL{n e t.TrowepSproyorcoatings rL'n ft h. Transits board, wall boarder—J c. Boller, breaching, duct, tank surfec000stings Ltn.ft. a. Corrugated or layered pin 225 pipe insulation r�L"i'n"."ft"�. ^''ry g. Spray -on fireproofing m' ft i. Cloths, woven fabrics k. Thermal, solid core pips [7M, insulation tt 14. Describe the decontamination system(s) to be used: 3 CHAMBER DECON j. other, please speciry: 15. Describe the contalnerizationldisposal methods to comply with 310 CMR 7.15 and 453 CMR 8.14(2)(a): 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? Q Yes ✓© No B. Facility Description 1. Current or prior use of facility: RESIDENTIAL 2. Is the facility owner -occupied residential with 4 units or leas? it Yes ©No 3. 4. ■ anf tot op.doc -10IO2 Asbestos NotillCation Fbrm • Pans 2 of 3 NOV-20-2013 16:24 FROM: TO:150e2617343 P.5 Commonwealth of Massachusetts . �ooysa5sa �'�; + Asbestos Notification Form ANF-001 Decal Number Note: Transfer Stations must comply with the Solid waste CNblon Regulations 310 CMR 10,000 B. Facility Description (cont.) S. �i..^Nam'e of General Cq%rara-ctorr b- Address I _ 1 Zip Cade e. Telephone Number area coda and extension) f. Contractors workers Camp- Insurer a. Polioy Number h. Ezo. Pate ImmJdd/my) 5. What is the size of this faoility7 Transportation and 1. Transporter of asbestos-Contalning material from site to temporary storage site (if necessary): AIRSAFE sme afTrsns o b Adtl c. City/rvwn d. ZIp Code e. Telephone Number 2- Transporter of asbestos -containing waste material from removaVtemporary site to final disposal site: 3. a D. Certification The undersigned hereby states, under the [OF WALSH penaltiesof perjury, that he/she has read theion Commonwealth of Maseaehuaett8 regulations N...ryy�, yp for the Removal, Containment or o. Poaitio frills Encapsulation of Asbestos, 453 CMR 6.00 and 81 762 9390 310 CMR 7,15, and that the Information contained in this notification is true and correct e. TalephonoNgint to the best of hismer knowledge and belief. 91 ENDICOTT 100206� 2 I. Zip Code 0 anropl ap.aoc -10102 Asbestos N0115000n Fonn - Palle 3 of 3 0