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Home My WebLink AboutMiscellaneous - 114 PLEASANT STREET 4/30/2018 (2) 114 PLEASANT STREET �t r � 210/070.0-0013-0000.0 10. HtrUSc i HANSr=H 5_fA1 IUN 1=AG;L I Y ANU UWrtEH(IF AFPLICASLE) Name: Telephone:( ) Street Address: City/Town: Owner's Name: (NOTE:Transfer Stations must comply with the Divisa)n ct Solid Waste Regulations 310 CMR 18.00.) t E PREPARER OF FORM 11. FINAL DISPOSAL SITE may! Name:_ � Telephone:( /�, a ,..? Name: ,N4' /'%l't�_,-//9?t`�CTelepho o:( 31Z)y s n Street Address: ! ' �itylTown: /4 Street Address: 0 c tai��?.o �►ity/Town '� !.G. THIS FORM MUST BE SIGNED BY—,HE OWNER OR 13Y THE RESPONSIBLE OPERATOR OFTHE PRC Owner's Name: POSED PROJECT (NOTE Disposal of ACM must comply with the Division at Solid Waste Regulations 310 CMR 19DQ) CERTIFICATION:I CERTIFY THAT I HAVE EXAMINED THE ABOVE AND THAT TO THE BEST OF M` KNOWLEDG T IS TRUE AND COMPLETE SIGNATURE SLtBJFCTS SIGNER TO THE PROVISION! 12. FOR EMERGENCY ASBESTOS REMOVAL OPERATIONS,NAME AND TITLE OF DEQE OF OF THE Gr L AT REGARDING.F E AND MISLEADING STATEMENTS). FICIAL WHO EVALUATED THE EMERGENCY Name: Title: A �� 1 ATURE) '� (TITL Date of Authorization: � J 4p ',Ad (REPT ESENTING) (DATE) D GENERAL DEMOLITION/RENOVATION DESCRIPTION 1. -DEMOLITION/RENOVATION CONTRA=R — Name: Telephone:( ) F REGIONAL OFFICE LOCATIONS Street Address: City/Town: - 2. ON-SITE SUPERVISOR AIR QUALITY SECTION.CHIEF AIR QUALITY SECTION CHIEF ` z - —DIVISION OF AIR OUAUTY CONTROL DIVISION OF AIR QUALITY CONTROL Name: — __METBOSMWNORTHEAST REGION _.__,__._'_SOUTHEAST REGION LAKEVILLE HOSPITAL S. SPECIFIC WORKSITE LOCATION(S): 5 COMMONWEALTH AVENUE MAIN STREET . WOBURN.MA 01801 - - -`""` IAKEVILLE,MA 02347 TELEPHONE (617)935-2160 TELEPHONE (617)947-1231 OR 727-1440 X680 4. WAS THE FACILITY SURVEYED FOR THE PRESENCE OF ASBESTOS CONTAINING MATERIAL OR 727-5194 _ (ACM)? yes no AIR QUALITY SECTION CHIEF. _ Alfl QUALITY SECTION CHIEF WHO CONDUCTED THE SURVEY? DIVISION OF AIR QUALITY CONTROL DIVISION OF AIR QUALITY CONTROL Name: WESTERN REGION STATE HOUSE WEST CENTRAL REGION 436 DWIGHT STREET.-41h FLOG: 75 GROVE STREET Department of Labor and Industries Certification N: SPRINGFIELD,MA 01103 WORCESTER,MA 01605 5. DEMOLITION/RENOVATION START DATE: EtID DATE MAIL TO:P.O.BOX 2140 TELEPHONE. (617)792-7653 6. DESCRIPTION OF DEMCLITIOWRENOVATION PROCEDURES TO BE USED I TELEPHONE. (413)785-5327 i —(NOTE.Demolition/Renovation Operatons must comply with 310 CMR 7.09 to conuol emissions to For official use Only: : ----prevent a condition of air pollution.) -- - - original resubmittal -FOR EMERGENCY DEMOLITIONIRENOVATION OPERATIONS.NAME,TITLE AND AUTHORI. TY OF STATE OR LOCAL OFFICIAL WHO EVALUATED THE EMERGENCY "^ --`- -- ' -- ------notification Incomplete/retumed Date certmall i`• a Name: - _.-Title: __ ... _ - 3. r aa1';r.•::::�`E',ta .,: tA&Rix`�"+R3w' ✓ ,.i;.:.r,. ,,.,, - da+S Sri-+- ;.::: 'Authority: - -Date of Authorization: (GENERAL STATEMENT tf Asbestos Containing Material is unexpectedt i bund or damaged during a Cte:nUt- -.... .- r . , ._:- . :;,�.. . .. j.. ' " tioNRenovation operation,all responsible parries must comply with 310 CMR 700,7A9,7:15 and C1lapter -- Mol the General laws aftheCommonwealth-This would include but would rid�e limited to fling an asoestos rem o al notifiication with the Ceeanment andior a notic3 cf a relea:erthrezt of Weasa ci a ha:3rdous subs?anca f COMMONWEALTH OF MASSACHUSETTS I C I ASBESTOS REMOVAL DESCRIPTION DEPaPTMENT OF ENVIRONMENTAL QUALITY ENGINEERING 1, ASBESTOS CCNTRA(iOR DIVISION OF AIR QUALITY CONTROL Name: - '�S�-� -ee TelePhan a:(L17/1) [SEE LAST PAGE FOR OFFICE LOCATIONS] Street Address: C,tylTawn: NOTIFICATION FORM FOR Department of Labor and Industries Certification l ASBESTOS REMOVAL AND GENERAL DEMOLITION/RENOVATION 2. ON-SITE SUPERVISOR Name: g,�, �6 A APPLICABILITY Department of Labor and Industries Canificat+ons S�n lL Demolition/Renovation operations involving asbestos-containing material(ACM)and.generat Demolt- 3- SPECIFIC WORKSITE LOCATION(S)(i.e.Building name,number,wing.Floor,room,tunnel.Is tion/Renovation operations are regulated by the Department of Environmental Quality Engineering the job indoor or ou(door?) (OEQE),D+v+son of Air Quality Control,under Regulations 310 CMA 7.00,709 and 7.15.Notification to the 4. ESTIMATED AMOUNT OF EACH TYPE OF ACM TO BE HANDLED(in linear and/or square feet) REGIONAL OFFICE of general demolitionlrenovation operations and demolitiontrenovation operations involving ACM isrequiredunder 310CMR 709(2)and 310CMR7.15(1)(b)twenty(20)days prior to any work // boiler,breeching,dud,tank surface coatings performed.The following information is reqquired pursuant to 310 CMA 715. thermal,solid core pipe insulation Copies of"Regulations for the Central of Air Pollution**,310 CMR 6.00 to 800 may be purchased from _corrugated or layered paper pipe insulation the State Bookstore, State House, Room 116, Boston, Massachusetts, 02133. Telephone number (617) 727-2834.Please PnnL insulating cement - _ � -, spray-on fireproofing trowe!lspray coatings cloths.woven fabric transite board,wall board B GENERAL PROJECT DESCRIPTION other.please describe 1. FACILITY TOTAL IN LINEAR FEET Name Aligh ` � �� Telephone: L `�3 TOTAL IN SQUARE FEET �- , Street Address:._i) � tY/Towns DESCRIPTION OF TECHNIQUES USED FOR ESTIMATION�•aL��d�l� -SL'�� Size of Facility:in square tees: 7�in number of floors: - Was the Facility built prior to 19807 yes_ no 6. .ASBESTOS REMOVAL START DATE:L6L� END DATE. psi ilio !� HOURS OF DAYS OF' Current or Prior use of Facility: OPERATION: __�aaytime OPERATION: Mon.-Fri. Is the Facility Occupied? Yes 1ff No evening Sat:Sun. _ night 2. FACILITY OWNER " (NOTE:Any changes in these dates must be reported to the appropriate regional office-If a removal Name: Telephone.( ). is postponed for more than thirty(30) calondar days, spearate notification will be required.1 Street Address: City/Town 7.- DESCRIPTION OF ASBESTOS REMOVAL PROCEDURES TO BE USED glove bag 3. ON-SITE MANAGER _j G full containment Name: 9/,4Telephone:( ) encapsulation enclosure Street Address: City/Town cleanup disposal only 4. GENERAL CONTRACTOR other-please describe '. Name; Telephone:( ) _, treat Address * Y Cit/Town __ III. TRANSPORTER OF ASBESTOS-CONTAINING WASTE MATERIAL FROM SITE TO TEMPORARY Y STORAGESit (IF NECc SARY)1D FINAL DISPOSAL.SITE x ,DceathisprojectInvolvetheremovat.and/walteration of any Asbestos Containing Material(ACM) - . Name: Telephone:(6/7),..;:27 as defined and atpplted In 310 C71R.T..00 and T:15? Yes . No Street Address: �l�u SAl>d.�►�f�C+tylTown � i/! ' �fff 9. µTRANSPORTER OF ASBESTOS-CONT AINING WASTE MATERIAL FROM REMOVAUTEM IF YES,you must soppy In full the Information requested In sections C through E below.IF NO. ) PORARY STOR/r*E SITE TO FINAL DISPOSAL LTE you must supply In full the Information In sections 0 and E. Name: L��-'f• ,/� 5�'d�' O� Telephone:( )