HomeMy WebLinkAboutEast St. #82 - 10/18/1995ds&zsLrs rhfngllcatlon Furm — ANF•001 f* .1� 1AS �e�3, a rtitj� k4a Lr,�9t
As6eslos AbafenionI DeserlpDon
1. Facility location:
......................... ..................... ..._ '8...:::F,c�sr s:1(e2
Adfrw
INSTRUCTIONS poor J`^C1$�3�r� 62.61
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I.tiudlaed Ns ............ ......... .r:...._............ _............. -- ..........
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GbAaa
lammudb ed '
bodvbwnptyrplywitN __¢p�f...5h2n 1J?5.................... _._.....___._.... __............ .....
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to Cop rdmsMd µalbhsob4 bolaal Dild+pnm, .ow nw..wo
Fmbodmnisl
Pndssllm noudcalbn 2. Is the facility ocoupled? Yes 0 No
rowienets of 310 CM
2.15 Jb!'WOamH 3. Asbestos
paJ!ol: rat ea .. ----NContractor:
trEactcto..r:
dwl.Ley .. y..�_ ..__._._..._......_......._.._!0�.�........s1.l_!,•.��._....
....:.+.......=p CJU�TIi
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0q sdmsM it Labor No"e snd lModnlas.............._l........._.......-...._0,1,,,,!.................................... ................. _V— .rvo_�..i._
d1S3CMt6.12 Join Gb/Tae Mwd rJap'ans
Agspim eoordw to
rpuiddANF._1....-...... \L.O_V..1..................................... .uni�rl fraF+rualNe'D+q
.............
aWnarlp'eAa Psre Gllawn/
fri Wsr liana
rCurs bet. A. On-Sqe Project SuparvlGsor�6yoLre,�m�anp
2. SnMrl QlyYul Form %.. J 1,I.1 .'.! s 'l.�..................................:........... ................ ..........
..._.....................�__.___
........._....................................................
le: Name IXrrws7rw/
Cs6m0aonslU of
Ilsancamdb 5. . Project Monitor.
Wisdu Pta/na
I.OJ. 120017 N.).�.................................................................................
....
.......................................
......
......
_.__._'___'_'_
. ........ .. _. IXlGdedkw /
lulse, MA 05112• Nrae
call
S. Asbestos AmFyllwl Lab:
2. Thhfommayb ...................____.____�_
Used wnan+wM N .1....1.. ...........................................................
_......_.-.......... _..... plrGdedM/ D
USA
ho*O otmelal More (ya D
h°inbeg Apscy P.obn ? . Project start dateJ_:ZJ—' dal elJJpr$pecglcworkhours(Mon: Fd.) 0 , (Sat.Sun.)
I of nDWot dendlian
["YAM opedlan '
ubadbNEstaps1p; S. What type ofproject isthis? (circle one): &T41e .0 mawrm oaarlwv+„1
6RISubprd bg
9. Describe the ubeslos abatement procedures to be used (circle): pan Ay sxaaar nAanJJssad dray
roc prde ga �
as ° �R axprelbs mlowDay o�JlL'p si�i JteS
10. Is the job being conducted ❑ Indoors Puldoors?
11. Total amount of each type of Asbestos Containing Materials (ACM) to be handled on pipes or ducts (linear It,) —or 01114(
surfaces (square fL) S�_to be removed, enclosed or encapsulated:
linear/square lest
IoM, ivF(Aby, Aat enl sufaro roallrps..._J Pwma(sol.Ucaepjw
tomgabda N}xadWCs'pfMkuufrNal...._J inubl0poemaa................
rW+ron 4gvsodrp.................... _J it wallwA)w coallain.............. _J
aklM, wowY fdrin..................... ir"Ho Dorn, waubosd............. _J
,)( dw(pkmdewrbe.........••...•••.•.--.15ru GF rKel les
J2. Discdbe the decontamination system(s) to be used: , `1
- _ ..........fc v.><<d......._..........._............................ ......... _...................... _..
............................................................ _..................
13. Describelhs
to comply wllh 310 CMR TO, and
...____....
fA. For Emergency Asbestos Abatement Openllpne, The DEP and DLl officials who evaluated the emergency:
P. wx.
Facility Descriptionu
1.
Current or pilot use of facility;
2.
__._._.._��__..._................... ..—........................._..........................__.......I._....._.............._..._._......
Is the facility owner -occupied residential with 4 untie or Isss7 Voa ❑ No
3,
Facility Owner.
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—
Ad w
WAow-_._.....___..___._.__.._........._................................ �... ....... ....... ........... —...........
.`f........................._.._.—:._�
4,
FacIIHy's Owner's On -Site Manager.
..................................C..1................................................................. .......................
................. ................. ............................... _._.._...
AOW
_..—_.___-._.._.—..__..._..............._..............._.._.._.................._.._....__...__._......__
Gy/laen Ih oxY
.lYAW9.....__..........__.........
5.
General Contractor.
p
........_i� 1....�r..a....................... ............... .............................. -.................. .....
..................................... ..... _..... ......_._...—
Nma Addnrr
—.._................ _....................... _.................... ............... _............ ._............ .......................................
gd/roxn Ito coda
.... .—.................................. __._......—....... —
feNpeanr
cun4acloia Waalnew'P.anunr Polry/
ft) floors)
rrp.041,
6.
What Is the the of the laellftyT�O (sit (/ of
13
Asbestos Transportation and Disposal
I.
Transporter of asheslos-containing waste material from site to temporary storage she (H necessary) to final disposal she:
1J............................ .......... ................. ....1..1_d..........G'..an....._Skrtefi.......s
... . .........36..
Nure .Wan
C/y/loen low*
fYNdnY
• 2. •
Transporter of asbestos -containing waste material from removaVtemporary storage
site to llnal disposal site:
>,<,..rin �ano...._ Tcc_k !....... tea....... s_ I!_v..�c".....s
Cho._ck_►_a ct..................... CT......... .......0. -_ y_ ...................._a
o.3.'._ ,a-o667
Nate: Transfer
•WRo+e JpmN
rYw.xa
Shllons, must 3.
empty w0A the
Refuse transfer station and owner (If applicable):
Solid Watt
DHlsbn regu6•
—__.—.----..__......-_.............................._..........................._...................................,....................._........................_....................._.._�..__
�wn ,taw
(tons 310 CMR
f6.00
'---._....... ._................................................................ ry........................................._.
abaam
r ......__.._...................... ... _.----
4.
Final Disposal Site:
Imlm NNn QxxnNm
.I ... _..................... _... .... .............. ....:............................................ .............. _.... ........_......... . - Address
...........................P...................................:............................................................
f+T/Roee Mmdr ............... .............../Yq�1m/
certification
The undersigned hereby stales, underline penaftles of perjury, that he/she has road the Commonweahh 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 nallllcallon Is true and correct to the best of his/her knowledge and belled.
a..m..._....L1.raa.�..4C W................................ .. c ..............._ ..' Q..'`.... J�-.-
hHlnmr AuowmasMu4Y _... aY
Nair. Contractor 50$ 8 W -Grid",
mwfsipn lM1r's P�.rj'')_�.1_ N 1
farm la DLl _.__ _._.. .... ___......_............_.........................._.-...................._e.'........................................._....................._.._.....___._
fte1WnII nN...... IYgYrvw
n0(tticahVn
purposes I.1.Q. Decto_.._�.:f.".................:.........._ i.�puni-fib....................._-0_a _$0.,_._
MYm axlf", lvo -
Fee exempt (City, Town, district, munlclpallhhoousing authority, owner-occupled residential of lour units or less) ?Ayes O no
Slicker / (from front of form): —10`
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