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Home My WebLink AboutHighland Ave. #22 - 10/2/1991(In 0�aqu i� ETA ��inr.I;lzlfr;e�Il#h of �a tts��Ie1IIIwe#i� DEPARTMENT OF LABOR AND INDUSTRIES DIVISION OF -INDUSTRIAL SAFETY 1110TIFICATICN OF ASBESTOS WOpr accordance with the provisions of M.C.L. C. 149, §6-6F and 453 C1?R 6.12) A11 sections e this. form the must be completed 'in order to comply wit: notification requirements of 453 CN.R 6.12 TEN DAY PRIOR NOTIFICATICN IS REQUIRED OF A1JY'ABATEMENT PRQ7ECT GREATER THAN THREE (3) LINEAR OR SQUARE FEET DLI FILE NUMBER Contractor perfornirg project 1 g QU /iL I T 14 66P6RT4 License ,r Do prevailing rates of wages apply to this project as required under M.G.L r_. 149, §26, 27 or 27F? (circle or .. YES 7iC Address of project Building ,Yana (if any) A 64eITE �/,SIaE Street Address ,. I )../� > /1 /"�p� /z G l/l s)'�J�� V C Ci ty ✓ 5 C 5og 58g 5yya Project type (circle one): DEMOLITION ` R:'NOVATIONI p.EPAIR OTHER ' If •Other• selected,.please explain Asbestos Activity: (circle one): EACAPSLZATIO.V ASSOCIAT3D PROJECT ENCLOSURE' REN.OV Indicate amount of: asbestos surface on pipes or ducts . OR LINEAR FEET on Pipes or ducts to be removed, enclosed orsbestos encapsulatedCe� ttuctures other than Start (fate Z5 UP.RE FEET an, J _ pm weekends? Completion Date Project Supervisor Name S. n.�r^^ � Certificate p�� Asbestosb Analytical LaName � lNA) eL Certificate y !n1 Namea 6 Address of disposal site(s) fill k DEG/L Xs asbestos contr.ic: written or•verbal2 C7ontsactcr's Workers' Conpcnsetlon lhsurer Policy Number_ ?agility owner Address City-- state n Zip Cescripc_'on, ..eof work practices to be followed: /{Q 12 Description of decentam�iration system(s) to be used CC0\( CPI AA9)f(I Description of hendlino/disposal Methods to comply with 453 CM4 6.I4(2) (q) 'a -me and address of transporters) if other than the asbestos contractor: is undersigned hereby staCesI under the penalties of perjury, that he/she has .ad and understood the Commonwealth of Massachusetts Regulations for the moval, Containment or Encapsulation of Asbestos, 953.C;!H G:00, and that the formation contained in this notification is true and correct to the best of sjher knowledge and belief. to (i, 16 ,�l ose return Ja/2 Signed: lli.S�� - � / jw Title: /� � S.LE2 v Company: 2 Q(I 4 L/ T 4 j o -- r.r- rr— �✓ Q�/vT iuoa � A v r this form to: So3v •7 Asbestos Control Technical Services 3 G� D-Part�nent of Labor anal Industries" Division of Industrial safety 100 Cambridge street, Room 1101 Poston, RA 02202 Massachusetts Departmenl of Environmental Protection Bureau of Waste Prevention —Air Quality BWP AQ 04 Asbestos Removal Notification ' BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos 7. Describe the demolition/renovation procedures to be used: (Note: Demolition/Renovation Operations must comply with 310 CMR 7.09 to control emissions to prevent a condition of air pollution.) Transmittari Facility 10 (it kno 8. Emergency Demolilton/Renovation Asbestos Removal Operations State, or local official who evaluated the.emergency:. AWW TIN Aura" Qak WAVIhatitalien (General Statement: It asbestos -containing material is unexpectedly found or damaged during a Demolilion/Renovalion operation, all responsible parties must comply with 310 CMR 7.00, 7.09, 7.15 and Chap(er 21 E of the General Laws of the Commonwealth. This would include but would not be limited to filing an asbestos removal notification with the Department and/or a notice of a roleaselthreal of release of a hazardous substance to the Department 0 applicable.) C81 twcatiol7 certify that I have examined the above and that to the best of my knowledge it is true and complete. The signature below subiects the sinner to the general statutes regarding a false and misleading statemenl(s). Cattlj ; 'rpl/�K.......l.�.o.»r.,Psa,�l....... C %I n ts�o �t�1��2� T PAnlN�me ••� AutluvlreOSlpnNun .............. .. .. ............ ............................................... .....n PauhNrine IL.TS Lute..........................�..:.. /..�.......�.(..................................... r. Rev, 1/91 Pa, Afassochusefts Department of Environmental Protection Bureau of Waste Prevention - Air ODality BWP.AQ 04 Asbestos Removal Notification r BWP AQ 06 Notification Prior to Construction or Demolition Permits for Asbestos 11. Transporter of asbestos -containing waste material frolry. .removalAemporary storage site to final disposal site 11ame 3 i UAIrvvaa n /<yE . scrunaeass Cly/Taan relepAone 12. Refuse transfer station facility and owner (if applicable) (Note.. Transfer Stations must comply with tho Solid Waste Division regulations 310 CMR 18.00.) 13. Final Disposal Site _4..... ........... ............ ....qO..%�LPGIf/Erf..R...li/EGP.;......... Adeless Cly?awn . .•• .. ....................... Wow WnrrNmf .. �' (Note. Disposal of ACM must comply vYilh'lf'Wsolid Wast Divisions regulations 310 CMR 19.00,)• 14. Emergency Asbastoi Rem oval0pdrAtlans:. DEP official who evaluated the emergency General Dom olilion/Renovalion Description 1. Demolition/Renovation Contractor Naar - __.._...__.....----------- - - .._..... Addecss Clry/iown --------- ieleOAone 2. On -Site Supervisor ................................................. Narte 3. Identify the specific Worksile Localion(s) 4. Was the facility surveyed for the presence of asbestos containing material (ACM)? ❑ Yes ❑ No If yes, who Conducted the Survey? .:................... ............................................................................... . Drjw&nenl al LaLne and Industries Cedlliallon / 5. If yes, who conducted the survey? ...................................................................................................... LkNebrirnla/LaMl asdlndutlers Ced!lioA'an/ 6. Demolition/Renovation Asbestos Removal fall Dare Rev. MI Pa; massactiusetts Department of Environmental Nrolectlon Bureau of Waste Prevention — Air Quality ................... - - 7ra&milCal BWP AQ 04 Asbestos Removal Notification --- ' BWP AQ 06 Notification Prior to Construction or Demolition i.............................. Permits for Asbestos FacilityID (i! know- 2. On -Site Supervisor / 7. Description of techniques used for estimation Nam T(�Q /�501 TA P�E ._.. Ikpv6nenldLaGnr and lnduslnes Cedlliatlan '—' 3. Hygienist .....F!_A ...�.L.E 4 A J.�.E._...�i �_A. �_S.'.. 5....... Na re 4. Specific Workshe Locations(s) (i.e. Building name, number, wing, floor, room, tunnel.) 5. is the job being conducted indoors or outdoors? i N7op.rL.` 6. Estimated amount of Each type of ACM to be handled boiler, breeching, duct, tank surface coatings thermal, solid core pipe insulation corrugated or layered paper pipe insulation insulating cement spray -on fireproofing trowel/sprayer coatings cloths, woven fabric transhe board, wall board other — please describe Total in Linear Feet Total In Square Feet Linear / Square Feet 8. Asbestos Removal . ............... al ....................................... ............... SbWale ....................... M.. _ ...'_ _..::.............:.: EndDale .......................................... urs of Operation W E daytime ❑ evening O night �ys of Operation Mon. —Fri. C3 Sat. —Sun. (Note: Any changes in these dates must be reported to the appropriate regional office. If a removal is postponed for more than thirty (30) calendar days separate notification wili be required.) 9. Describe the asbestos removal procedures to be used. ...........�...:.1.5 ❑ glove bag ❑ enclosure JV full containment ❑ cleanup ❑ encapsulation ❑ disposal only / 0 other -please describe ...... / 10. Transporter of asbestos -containing waste material from site to temporary storage site (if necessary) to final disposal siie Rev. 1/gi Page 2 of 2rn`i ; `� OEPr• 'ewOfPV" t1r^-_ NMI Recervsd Wh-,,,, m NMI OAppt. oDWed Dalebn Date,,,,,, • ICassachusens vellartment of Environmental Protectloll Bureau of Waste Proven[ion —Air Oualiry L ,7!. �' BWP AQ 04 Asbestos Removal Notification BWP AQ 06 Notification Prior Transmittals to Construction or Demolition Permits for Asbestos facility to 01 know ' Applicability Demolition/Renovation operations involving asbestos- containing material (ACM) and general DemolhiorL/Renovation renovation operations and demolition/renovation operations involving ACM is required under310 CMR 7.09 (2) and 3.10. operations are regulated by the Department of Environmental Protection (DEP), Bureau of Waste Prevention—Alr Quality CMR 7.15 (i) (b) twenty (20) days prior to any worktieing: performed. The following information is required' ' " ' ' to Division, under Regulations 31'0 CMR 7.00, 7.09 and 715.. 310 CMR 7.15: Notification to the REGIONAL OFFICE of general demolition/ General Project Description 1. Facility nIA.:.1_6.R.:.1.. _,. .................. _.,........... r N �I n� r 3. On -Site Manager .. .. .. Address.......... ........................ ' A.4 ClygDwn ...a�.7....._........ u................_.._ _ ................: SQ .....5 ....... yo Telephone .............................:. Size d 0 0 .. Numberallkaa•._...........».__......_._.......... Was the Facility built prior to 19807 ®" Yes ❑ No i ESI �C_NCe _......_._ ��._ ..............._.._._......._�. ........ CumnfaPdorutt olfxlgry //.........__......_............ Is the Facility Occupied? . 0" Yes ❑ No Is this Facility Owner -Occupied Re ' endai with 4 units or less? P/Yes ❑ No 2. Facility O0wn]erq� .......1.�..`:!...�.`:._6........ Narar!.......!...,/...... .E.................. Address Clyoo" Telephone LIA Asbestos Removal Description 1. Asbestos Contractor Nf�.l....v r7y.ETs..................... .. eF.—•. � WO6� � Vz Addnss............................................................... Rev.1/91 Address Clynoa_---....... ... ....._.._...w._..____.................. _.... ....... ..._...,....__...._......__...._...._ ._.. .r _ _.—.._._.... Telephone .... 4. General Contractor Clly/rown Telephone Does this project involve the removal and/or alteration of any Asbestos Containing Material (ACM) as defined and applied In 310 CMR 7.00 and 7.1577 Kes O No If Yes, complete Sections C and D. If No, complete Sections D and E. oyrrewn—� Telephone --_. �Coa6 i6�(/ LkDrrerunl olLaoorarW lnduslder Lrarae/ —` Page 1 of e