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Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
A. Asbestos Abatement Description
■
100188097
Decal Number
RECEIVED
CCT ? 9 2013
HEALTH DEPARTMENT
1. a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied
residence of four units or less? F/� Yes n Nn
b. Provide blanket decal number if applicable.
2. Facility Location:
INSTRUCTIONS 3
1. All sections of this
form must be
completed in order
to comply with 4.
DEP notification
requirements of 310
CMR 7.15 5.
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CMR 6.12
10
0
N
0
0
o
LL
STEVE SMOLAK
a. Name of Facility
NORTH ANDOVER MA
c. City/own d. State
Blanket Decal Number
12 YOUNG ROAD
b. Street Address
01845
e. Zip Code f. Telephone Number
Worksite Location:
BASEMENT
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
Is the facility occupied? ❑✓ Yes ❑ No
Asbestos Contractor:
ANEW ENGLAND SURFACE MAINTENANCE
a. Name
WEYMOUTH e� 02189
c. Ci /Town d. Zip Code
AC000196
f. DOS License Number
6 [JOSE VILLALTA
a. Name of On -Site Supervisor/Foreman
7 OWNER'S REP
a. Name of Project Monitor
8 OWNER'S REP
a. Name of Asbestos Analytical Lab
9. 11 /08/2013
a. Project Start Date mm/dd/
8-4
c. Work hours Mon -Fri.
10. a. What type of project is this?
❑ Demolition ❑ Renovation
❑✓ Repair ❑ Other, please specify:
11. a. Check abatement procedures:
❑ Glove bag ❑ Encapsulation
❑ Enclosure ❑ Disposal only
❑ Cleanup ❑ Other, specify:
❑✓ Full containment
850 WASHINGTON STREET
b. Address
7813372117
e. Telephone Number
g. Contract Type: ❑ Written ❑ Verbal
b. Describe
b. Describe
�Q 12. Is the job being conducted: ❑✓ Indoors? ❑ Outdoors?
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Asbestos Notification Form • Page 1 of 3 0
LiCommonwealth of Massachusetts
Asbestos Notification Form ANF -001
Z
Q
A. Asbestos Abatement Description (cont.)
■
100188097
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
enca sulated:
100 1 130
a. Total pipes or ducts (linear ft) otal other surfaces square
c. Boiler, breaching, duct, tank
30
surface coatings
Lin. ft.
Sq. ft.
d. Insulating cement
Lin. ft
e. Corrugated or layered paper
100
C�
rum
pipe insulation
Lin. ft.
S . ft.
f. Trowel/Sprayer coatings
g
Lin. ft.
Spray fireproofing
�
g. -on
Lin. ft.
Sq. ft.
h. Transite board, wall board
Lin. ft.
i. Cloths, fabrics
C�
woven
Line
S�
j, Other, please specify:
Lin. ft.
k. Thermal, solid core pipe
insulation
Lin. ft.
Sq. ft.
I. Specify
14. Describe the decontamination system(s) to be used:
AS REQUIRED
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (q):
REQUIRED
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
a. Name of. DEP Official b. Title
C. Date mm/dd/ of Authorization d. DEP Waiver#
e. Name of DOS Official f. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver
ft.
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? ❑ Yes 2✓ No
B. Facility Description
1. Current or prior use of facility: (RESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? [aYes []No
SAME
3' a. Facility Owner Name b. Address
c. Ci /Town d. Zip Code e. Telephone Number area code and extension
4' a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address
c. City/Town d. Zip Code e. Telephone Number (area code and extension)
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Note: Transfer
Stations must
comply With the
Solid Waste
Division
Regulations 310
CMR 19.000
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
B. Facility Description (cont.)
5' a. Name of General Contractor
F
c. Ci /Town d. ZiD Code
f. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
100188097
Decal Number
e. Telephone Number (area code and extension
Policy Number h. Exp. Date mm/d
a. Square Feet b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
NESM, LLP
a. Nam.._ e of Transporter
if
c. City/Town d. Zip Code
b. Address
e. Telephone Number
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
RED TECHNOLOGIES
a. Name of Transporter �j b. Address
c. Cit /Town d. Zip Code e. Telephone Number
3.
a. Refuse Transfer Station and Owner � b. Address
c. Clty/Town d. ZID Code e. Telenhnna Numhar
4. IMIN
a. Fir
e. State
A ENTERPRISES INC I I
Location
ROAD I IWAYNESBURG
D. Certification
V. l..11 /I.VYYII -
44688
f. Zip Code g. Telephone Number
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth 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 notification is true and correct
to the best of his/her knowledge and belief.
JIM DOYLE
a. Name b. Authorized Signature
10/28/2013
C. Position/Title d. Date mm/dd/
NESM, LLP
e. Telephone Number f. ReDresentina
g. Address
h. City/Town I. Zip Code
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