HomeMy WebLinkAboutMiscellaneous - 1099 SALEM STREET 1/10/2018 (2) Massachusetts Department of Environmental Protection s �
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w 100261
SWP AQ 04 (ANF-001)
µ� Asbestos Project#
Asbestos Notification Form f°" Project]revision
REGENEGellatrcrn
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A. Asbestos Abatement Description TOWN OF NORTH ANDOVER I
HEALTH DEPARTMENT
p
1.Facility Location: 1
RESIDENCE 1099 SALEM STREET
Instructions 1.All a.Name of Facility b.Street Address
sections of this form NORTH ANDOVER
must be completed in MA 01845 5085728224
order to comply with c.City/Town T State e.Zip Code f.Telephone
MassDEP notification BOB INNIS OWNER
requirements of 310
CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title
Department of Labor Worksite Location: BATHROOM AND OUTSIDE
Standards(DLS)
notification i.Building Name,Wing,Floor,Room,etc.
requirements of 453 2. Is the facility occupied? W 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 less)? W a.Yes I— 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 E&F ENVIRONMENTAL SERVICES LLC 86 CAROLAN AVE
a.Name b.Address
HAMPTON NH 03842 6032345581
c.City/Town d.State e.Zip Code f.Telephone
AC000767 h.Contract Type: IV 1.Written �u 2.Verbal.
g.DLS License#
GUILLERMO A MARGARIN FRIAS AS060373
7.
a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification#
N/A
8.
a,Name of Project Monitor b.DLS Certification#
ASBESTOS NOTIFICATION LABORATORY AA00208
9.
a.Name of Asbestos Analytical Lab b.DLS Certification#
10.
8/8/2017 8/9/2017
a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY)
7:00-3:30 N/A
c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday
I
11.What type of project is this? i
I" a.Demolition f- b.Renovation I—' c.Repair ri d.Other-Please Specify: REMOVAL
Revised: 11/1.3/20113 Page 1 of
Massachusetts Department of Environmental Protection
��\i
BWP' A 04 ANF-001 isIbest s IP
/ Asbestos Project#
`' w` Asbestos Notification Form
�� r" ProjeclRevisicyn
r- Project Cancellation
A.Asbestos Abatement Description: (cant.)
12.Abatement procedures(check all that apply):
r. a.Glove Bag r b.Encapsulation r, c.Enclosure r' d.Disposal Only r'" e.Cleanup
W f.Full Containment IV g.Other-Please Specify: POLY SURROUNDING STRUCTURE
13.Job is being conducted: IV a.Indoors IV b.Outdoors
14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or
encapsulated:
200 60
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 c.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 Speci ly:
1.Lin.Ft. 2.Sq.Ft.
j.Insulating Cement LINOLEUM AND WNDOW GLAZI 200 60
1.Lin.Ft. —TS Ft, 1.Lin,Ft, 2.Sq.Ft.
15.Describe the decontamination system(s)to be used:
FULL CONTAINMENT AND POLY SURROUNDING STRUCTURE
16.Describe the containerization/disposal methods to comply with 310 CMR 7.1.5 and 453 CMR 6.14(2)
(g):
ALL METHODS WILL COMPLY
17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency:
a.Name of MassDEP Official b.Title of MassDEP Oficial
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. 1.49, § 26,27 or 27A—F apply to this r— a.Yes IV b.No
project?
Revised: 11/13/21713 Page 2 of
Massachusetts Department of Environmental Protection --
10026 561
BWP AQ 04 (ANF-001) _. .
Asbestos Project#
Asbestos Notification Form
r'W Project Revision
l„- Project Cancellation
B. Facility Description
1.Current or prior,use of facility: RESIDENCE 1
i
2.Is the facility owner-occupied residential with 4 units or less? IV a.Yes I— b.No
3.
BOB INNIS 1099 SALEM STREET
a.Facility Owner Name b.Address
NORTH ANDOVER MA 01845 5085728224
c.City/Town d.State e,Zip Code f.Telephone
4.N/A N/A
a.Name of Facility Owner's On-Site Manager b.Address
N/A MA 00000 0000000000
c.City/Town d.State e.Zip Code t.Telephone
$'N/A N/A
a,Name of General Contractor b.Address
N/A MA 00000 0000000000
c.City/Town d.State e.Zip Code f.Telephone
LIBERTY MUTUAL INSURANCE
g.Contractor's Worker's Compensation Insurer
000000000 1211312017
h.Policy# i.Expiration Date(MMIDD/YYYY)
6,What is the size of this facility? 1100 1
a.Square Feet b.#of Floors
C. Asbestos Transportation & Disposal
1.Transporter of asbestos-containing waste material from site of generation:
lw— a.Directly to Landfill or IV b.To Temporary Storage Location/Transfer Station
E&F ENVIRONMENTAL SERVICES LLC 86 CAROLAN AVENUE
c.Name of Transporter d.Address
Note:Temporary
storage of Asbestos HAMPTON N-1 03842 6039742503
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 Asbestos
contractor or a transfer waste material from temporary storage location/transfer station to final disposal site:
station that is
permitted by SERVICE”TRANSPORT GROUP,INC. 58 PYLES LANE
MassDEP and a.Name of Transporter b.Address
operated in
compliance with Solid NEWCASTLE DE 19720 8779999559
Waste Regulations
810 CMR 19.040 c.City1rown d.State e,Zip Code f.Telephone
Revised: 11/13/2013 Page 3 of 4
Massachusetts Department of Environmental Protection
Ll
BWP AQ 04 (ANF-401) sbest s61
Asbestas Praject#
Asbestos Notification Norm ��`" T roject Itewision
I-- Project Cancellation
C.Asbestos Transportation& Disposal: (cont.)
3.Name and address of temporary storage location/transfer station for the asbestos containing waste
material:
NIA NIA
a.Temporary Storage Location Name b.Address
NIA NIA 00000 0000000000
c.Cityfrown d.State e.Zip Code f.Telephone
4.Name and location of final disposal site(asbestos landfill):
MINERVA LANDFILL N/A
a.Final Disposal Site Name b.Final Disposal Site Owner Name
9000 MINERVA ROAD
c.Address
WAYNESBURG OH 44688 3308663435
d.City/Town e.State f.Zip Code g.Telephone
D. Certification
FRANK BALOGH FRANK BALOGH
"I certify that I have personally 1.Name 2,Authorized Signature
examined the foregoing and am OANER 7/26/2017
familiar with the information
contained in this document and 3.Positionffitle 4.Date(MMIDDlYYYY)
Note:Contractor must 6039742503 E&F ENVIRO
sign this form for DLs all attachments and that,based
notification purposes on my inquiry of those 5.Telephone 6.Representing
individuals immediately 86 CAROLAN AVENUE HAMPTON
responsible for obtaining the 7.Address 8.City/Town
information, I believe that the N-1 03842
information is true, accurate,and 9.State 10.Zip Code
complete.I am aware that there
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