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Commonwealth of Massachusetts ■
100007080 —1
Asbestos Notification Form ANF-001 ----Decal Number
Affix Asbestos
Notification Decal
Here
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 ❑ No
I
b. Provide blanket decal number if applicable: Blanket Decal Number
2. Facility Location
DEREK PRICE
a Name of Facililv
Mansfield == IMA
c. City/Town d. State
387 WILLOW ST.
b. Street Address
02048
e. Zip Code I. Telephone Number
INSTRUCTIONS 3. Worksite Location:
1. All sections of this !BASEMENT
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
NEW ENGLAND SURFACE MAINTENANCE
of Occupational
Safety (DOS)
a. Name
notification
IWEYMOUTH
02189
requirements of 453
i _
CMR 6.12 a
P
jJOHN
P VALLIQUETTE
6
a. Name of On -Site Su ervisor/
S.COHEN
7
a. Name of Project Monitor
jENVIROTEST
LAB
8
a. Name of Asbestos Analytical
08/2412004
9.
a. Project Start Date (mm/ddh
10. a. What type of project is this?
Demolition ❑✓ Renovation
LJ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
1850 WASHINGTON STREET
b. Address
17813372117
e. Telephone Number
g. Contract Type: ❑ Written ❑ Verbal
b. Describe
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
✓I✓I Full containment b. Describe
12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
■ anf001 ap.doc • 10102 Asbestos Notification Form • Page 1 of 3 ■
Commonwealth of Massachusetts ■
i (�00007oso �
Asbestos Notification Form ANF-001 Decal Number
A. Asbestos Abatement Description (cont.)
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
100enca sulated: 80
a. Total pipes or ducts (linear ft) Ta of7o er su aces square
c. Boiler, breaching, duct, tank
J
30
surface coatings
Corrugated layered
Lin. ft.
100
Sq. ft.
d. Insulating cement
Lin. ft.
Sq. ft.
e. or paper
pipe insulation
Lin. ft.
Sq. ft.
f. Trowel/Sprayer coatings
Lin. ft.
Sq. ft.
50
g. Spray -on fireproofing
Lin
Sq�
h. Transits board. wall board
Lin.
ft
i
i. Cloths, woven fabrics
Lin. ft.
S . ft.
rl
j. Other, please specify:
Lin. ft.
Sq. ft.
k. Thermal, solid core pipe
insulation
Lin. ft.
Sq. ft.
I. Specify
14. Describe the decontamination system(s) to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
REQUIRED
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 ❑✓ 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
0
4.
■ anf001ap.doc• 10/02
Asbestos Notification Form - Paa eM
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF-001
B. Facility Description (cont.)
6
a. Name of General Contractor
c. City/Town d. Zi Code
I. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
a.
C. Asbestos Transportation and Disposal
100007080
Decal Number
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
�NESM
a. Name of Transporter
i
c. City/Tom d. Zip Code
b. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
WASTE MANAGEMENT
3.
4. !TURNKEY LANDFILL
7 ROCHESTER NECK ROAD I
e. State
D. Certification
03839
f. Zip Code g. Telephone Number
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
b. Authorized Signature
07119/2004
c. Position/Title
d. Date mm/dd/
e. Telephone Number
I. Representing
Address
_
F
��
I. Zip Code
h. Cityrrown
0 anf001ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3
NES
NEW ENGLAND SURFACE MAINTENANCE, LLP
ENVIRONMENTAL SERVICES
April23, 1999
DEP
DLWD
EPA
BOH
The following project has been canceled at the owner's request.
Pepin
89 Willow Street
Mansfield, MA 02048
DEP Sticker #: 734231
Scheduled Work Date: May 11, 1999
Any questions regarding this matter may be directed to Jim Doyle at 781-337-2117.
irface Maintenance, LLP
TAUNTON WEY-.MOUTl1 BOSTON FAX NUMBER BER TOLL FREE NUMBER
(5()8) 88()-0019 (781)337-2117 (617)426-1685 (781) 37-5690 1-SOO-39-5476