HomeMy WebLinkAboutBellavista Ave. #46 - 7/15/1992'� �'' ✓ihe 'Cn:'r?i�Ou�pti � a/%Yq'44C1Cr4�tk�t9dt`4 •
ItOTIFICAPrON OF ASBESTOS WORK
(In accordance with the, provisions of 14,0.1,, C, 149, 66.6F enQ 459 CNR 6.22)
All sections of this Form oust to completed in order to comply with
the notification requirements of 453 CMR 6.12
TEN DAY PRIOR HOUPICATrON IS REQUIRED OF ANY ABATEMENT 'PROVEC'P .
GREATER THAN.THREE (3) LINEAR OR SQUARE FEET •.
DLr FILE NUMBER
Contractor performing project AirSafe international License'# AC 000011
to prevailing rates of wages apply to this project as required
under M.O.L c. 149, $26, 27 or 27F? (circle one) YES NO
Address of Pro ect
Building Name (if any)�l / �l�k'. M1 ��1 ( `� o
Street.
city • !ll'f/�S��iNI�! Ztp ..
Project We (circle one): DEMOLITION RENOVATION EPAI , OTHER
If •Other• selected, please explain
Asbestos Activity: (circle one): BNCAPSULArtON
ENCLOSURE
ASSOCrATED PROJECT
REMOVAL �
Indicate amount of: asbestos surface on pipes or ducts, Z0zINEAR FEET
OR
asbestos surface on structures other than pipes or ducts
to be removed, enclosed or encapsulated SQUARE FEET
Start date_ am-..... Pmw weekends? 196
Completion Date y
Project Supervisor Name K yin C2LnQIiEsen Certificate k.SF11892�
Asbestos Analytical Lab Name Certificate N
Name 6 Address of disposal sites) Ham Sanitar Landfill SWF-2032-86-M1
-Boz'22 E2%1d4 P.o. Box 576, Peterstown, WV 24963
0049all
Is asbestos contract written or verbal?
writ ten
ConteactorPS Workers Compensation rnsurer_Libey y Ml LUA.l
Policy Number_ wr.l-3l2-arnaan.nin
Facility Amer
Address Of 8e-flarls b3(-1
City i / /%s ( State MA tip.
Desaripttoq of work practices to be followedr Proper Glove Ba Removal
Description of decontamination systemfe) to be used Mini 1-2 Chamber, 6 mil
poly decontamination facility (clean room and dirty/wash for two chambers).
Description of ha»81lgq/dtsposaT methods to comply with 453 C" 6.1401 (q)
Keep ACM
Name and address of transporter(s) if other than the asbestos contractor:
Bluegrass
Transportation Co.
Inc.
P.O.
Box
351 •Catlettsbiir
KY '41 29
The undersigned hereby states, under the penalties of perjury, that..he/she has
read and understood the commonwealth of Massachusetts Regulations, for the
Removal, Containment or 6ncapsulatlon of Asbestos, 453 CUP 6..00, and that the
Information contalned in this notification is trve and correct to the best of
his/her knowledge and belief.
Date C4'1/`i 2- "".«..."" Signedr
Title: P, roject CoordinaLQj
Company: AirSafe 112-ternati�nal, Ltd
Please return this form to:
Asbestos Control Technical Services
Department of labor and Industries
Division of rndustrial Safety
200 Cambridge Street, Roam 1101
Boston, MA 02202
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