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Home My WebLink AboutMiscellaneous - 83 ACADEMY ROAD 11/29/2017 Massachusetts Department of Environmental Protection eDEP Transaction Copy ................................................................. Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: NANCYT Transaction ID: 966102 Document: AQ 04-Asbestos Removal Notification Form ANF-001 Size of File: 235.87K Status of Transaction: In Process Date and Time Created: 10/31/2017:1:34:20 PM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) PreForm Asbestos Notification Form L L J This is a revision to an existing form. Project ID for existing form to be revised: This job is being conducted under a Blanket Permit. MassDEP assigned Blanket Authorization ID: This job is being conducted under a Non Traditional Abatement Work Practice Permit. MassDEP assigned Non Traditional Work Practice Authorization ID: This job does not require the use of an asbestos contractor licensed by the MA Department of Labor Standards because(please check one box below): This job involves breaking,shearing or slicing of non-friable asbestos-containing material only(e.g.cement shingles/panels,cement pipe,asphalt roofing or siding,vinyl floor tiles,etc.)in a manner that does not generate asbestos dust or render the material friable,as allowed by the Department of Labor Standards(DLS)at 453 CMR 6.13(2)(a)5. All work must be done in compliance with the applicable regulations at 310 CMR 7.15;or This job involves work on asbestos containing material that is classified by the Department of Labor Standards (DLS)as a`Small-Scale Asbestos Project,' an`Asbestos-Associated Project',or an`Asbestos Response Action' by qualified`in-house'personnel as allowed by the Department of Labor Standards(DLS)at 453 CMR 6.00,and will be performed in accordance with all the requirements of 453 CMR 6.13 (1)(a),453 CMR 6.13 (2)(a)1. and 3., and 453 CMR 6.14(1)(a), as applicable. All work must be done in compliance with the applicable regulations at 310 CMR 7.15. None of the above conditions apply,generate a new form. Revised: 11/13/2013 Page 1 of 1 Massachusetts Department of Environmental Protection 100275196 BWP AQ 04 (ANF-001) Asbestos Project# w� Asbestos Notification Form I'""` Project Revision r", Project Cancellation A. Asbestos Abatement Description 1. Facility Location: KATHY STEVENS 83 ACADEMY RD Instructions 1.All a.Name of Facility b.Street Address sections of this form NORTH ANDOVER must be completed in MA 01845 9786835522 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification KATHY STEVENS OWNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: BASEMENT AND BARN Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility Occupied? I a.Yes I b.No CMR 6.12 3. Is this a fee exempt notification (city, town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or Tess)? II'r a.Yes II""" b. No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 AIR SAFE INC 22 WILLOW STREET a.Name b.Address CHELSEA MA 02150 9783395361 c.City/Town d.State e.Zip Code f.Telephone AC000464 h.Contract Type: l 1.Written I""2 Verbal g.DLS License# 7 SEBASTIAN GAITAN AS000597 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8. KATTIA LOPEZ AM900491 a.Name of Project Monitor b.DLS Certification# 9 ASBESTOS IDENTIFICATION LAB AA000208 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 11/13/2017 11/14/2017 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7AM-6PM NA c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? r"° a.Demolition r b.Renovation r"""" c.Repair r"° d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r,,, Project Revision r", Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): l a.Glove Bag r" b.Encapsulation r", c.Enclosure r" d.Disposal Only r" e.Cleanup I f.Full Containment r", g Other-Please Specify: 13. Job is being conducted: Vim` a. Indoors �(.- b. Outdoors 14 a. Total amount of each type of asbestos Containing materials (ACM)to be removed,enclosed,or encapsulated: 330 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b. Boiler, Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 330 e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i. Other- Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15. Describe the decontamination system(s)to be used: THREE CHAMBER DECON 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L. c. 149, § 26,27 or 27A—F apply to this r," a.Yes V'+` b.No proj ect? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r,,, Project Revision r", Project Cancellation B. Facility Description 1. Current or prior use of facility: RESIDENTIAL 2. Is the facility owner-occupied residential with 4 units or less? a.Yes b.No 3 KATHY STEVENS 83 ACADEMY RD a.Facility Owner Name b.Address NORTH ANDOVER MA 01845 9786835522 c.City/Town d.State e.Zip Code f.Telephone 4 KATHY STEVENS 83 ACADEMY RD a.Name of Facility Owner's On-Site Manager b.Address NORTH ANDOVER MA 01845 9786835522 c.City/Town d.State e.Zip Code f.Telephone S NA N/A a.Name of General Contractor b.Address NORTH ANDOVER MA 01845 9786835522 c.City/Town d.State e.Zip Code f.Telephone N/A g.Contractor's Worker's Compensation Insurer N/A 12/31/2017 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 2470 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1. Transporter of asbestos-containing waste material from site of generation: V'r" a. Directly to Landfill or V' b. To Temporary Storage Location/Transfer Station AIR SAFE,INC 22 WILLOW ST c.Name of Transporter d.Address Note:Temporary storage of Asbestos CHELSEA MA 02150 9783395361 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2. If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestoswaste material from temporary storage location/transfer station to final disposal site: contractor or a transfer p y g p station that is permitted by SERVICE TRANSPORT GROUP 58PYLESLN MassDEP and a.Name of Transporter b.Address operated in compliance with Solid NEW CASTLE DE 19720 8779999559 Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r- Project Revision r- Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE,INC 22 WILLOW ST a.Temporary Storage Location Name b.Address CHELSEA MA 02150 9783395361 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES,INC a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA RD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone D. Certification DFW DFW "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am VP 10/31/2017 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) Note:Contractor must 9783395361 AIR SAFE,INC sign this form for DLS all attachments and that, based notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 22 WYCHWOOD DR LITTLETON responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 01460 information is true, accurate,and complete. I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment. The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4