HomeMy WebLinkAboutSo. Main St. #64 - 10/19/1989�` ., C49 (9AIIIutIIufutaft4 of Ansonr4uset#$
DEPARTMENT OF LABOR AND INDUSTRIES
DIVISION OF INDUSTRIAL SAFETY -
NOTIFICATION OF ASBESTOS WORK
lbaccordance with the provisions of M.G.Z. c. 149, §6-6F.and..453 CMR 6.12)
Al2 sections of this form must be completed in order. to comply with
the notification requirements of 453 CMR 6.12
TEN DAY PRIOR NOTIFICATION IS REQUIRED OF ANY ABATEMENT PROJECT
GREATER THAN THREE (3) LINEAR OR SQUARE .FEET
DLI FILE NUMBER
Contractor performing project Bay Insulation Systems, In
c=Cense p AC000020 "
Do prevailing rates of wages apRly to this project as required under M.G.L C. 149, §26, 27 or.27F? (circle one)
YES �O
Address of Protect
__ Bullding.Name_(if 'any)._..
Street Address
City Zip
Phone
Project type (circle one): DEMOLITION NOVATI REPAIR
OTHER
If *Other* selected,please explain
Asbestos Activity: (circle one): ENCAPSULATION
ASSOCIATED PRQ7ECT
ENCLOSURE REMOVAL
Indicate amount of: asbestos surface on pipes or ducts
-- LINEAR FEET
OR
asbestos surface on structures other than
Pipes or ducts to be removed, enclosed or encapsulated <,�/j �t{/_SQUARE FEET
Q�
Start date ' ���am
� pm L
weekends? �ZfJ
Completion Date /0'/' /-
Project Supervisor Name
Certificate ,q—SCIZ2<�—
Asbestos Analytical Lab Name �—
Certificate p
Name B Address of disposal site(s)_ Consolidated Waste
'd eviock:. ME...
0049all
is asvescos contract written or verball_.��..���/t�j�
Contractor's workers compensation .Znsurer
INA
P021Cy Number WOcc214592'
Facility owner
Address
City
state
Of work practices
Description of
be followed:
to be used
Description of handlingldisposa2 methods to comply with 453 CMR 6.14(2).(g)
DOUBL .
Name and address of transporterfs) if other than the asbestos contractor:
_. --Z,ruv_ironmental Waste
1039 Chestnut St., Newton Upper Falls, Ma
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.Sncapsulation of Asbestos, 453 CMR 6.00, and that the
information contained in this notification is his/her knowledgetrue and correct to the best of
-'7Qand be2tef.
Date [� / !�% Signed:
Title: PRESIDENT
Company: BAY INSULATION SYSTEMS,INC.
Please return this form to:
Asbestos Control Technical Services
Department of Labor and industries
Division of Industrial Safety
200 Cambridge Street, Room 1102
Boston, MA 02202
0049a12