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HomeMy WebLinkAboutMiscellaneous - 1099 SALEM STREET 1/10/2018 (2) Massachusetts Department of Environmental Protection s � 56 w 100261 SWP AQ 04 (ANF-001) µ� Asbestos Project# Asbestos Notification Form f°" Project]revision REGENEGellatrcrn AUG 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