HomeMy WebLinkAboutMiscellaneous - 301 Middlesex Street 'gel
1_x Commonwealth of Massaohus t�s °ARA
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Asbestos Notification Form -- NF 0 3 0 r, 5 V.
�� 'I
Asbestos Abatement Dest±riptlon
1. Facility ation:
I11MUCTIONt
1. AN seriioro of this _—� " G - +'� o�' 5. --.. _. ._._ ' �`� I 0
fano must be completed city/Town ------------ - ---- — 171 cz V - rerepAorN
in order to comp y with
the Department of --- _ -- ��-- - - - - -- - ------ - --�
EmIronmental H is ft iwraire Jocanon7 tlurrdlnp nam,/,wtnp,r
Protectlon notification 2. Is the facility occupied? j-.Aes ❑ No
mWitemerts of 310 CMR
7.1S (10 working days
Prior nouracsfionis 3. Asbestos Contractor;
rewisdolsnyabstement ASBESTOS MAN REMOVAL CO. 6 REVERE RD
Avio;and It --—
Deportment o1 labor Naar -- - - --
Aruraet
u11Irrlionr
rafiticalion reqquu irements QUINCY� MA 02169 ( 61 7 ) 471 -6380
of 453 CMR 6.12 (len
dip prior nofficstion a
re*WotANY AC 000342 _ WRITTEN
sbsferarM proirct Oreafer
to*w liner or LYllkan�/ L.Mfad lige(01NOerbal) ---
sw "10. 4, On-Site Pr 'ect Supervisor/Foreman:
2. Submit Original Form
-- ------ - ---- -- S' tl i
emus eualth 61 � L?i+auk anon/
Maauebmtts 5. Project Monitor:
1tskdaPrognm ENVIRO TEST
►.O.t.110081 AA 000128
8atee,MA 02112•
0087
6. Asbestos Analytical lab:
3. TMIormmaybe ENVIRO TEST AA 000128
used for notifying the ------------- — --
U.S.Environmental Namr - — - ---- -------_-----
cxr��mr�arurn/
Ptolection Agency Region
I of asbestos demolition/ 7. Project start date L/)-7/'fiend dateL!1l/ spec;f lc work hours Mon.-Fri. G d'3'J 0
renovation operations
— ( ) � (sat.Sun.)
subject to NESHAPS(40
CFA Subpart M). 8. What type of project is this? (circle one): owr6i or, rev/r nvavanon oear(axplaln)
Fa Mad LbeONy 9. Describe the asbestos abatement procedures to be used (circrey pmrobw *xwun ' Juuconfynmanl dNnup
' soe4asuprim aspawonly Awr(iAAI,;)
�M1d0e1 10. Is the job being conducted
X indoors D outdnc�rs
mad 11. Total amount of each type of Asbestos Containing Materials;ACM)to be handled on pipes or ducts(linear ft.) �- rJ or other
oomm D* surfaces(square ft.)_rl'o �to be remover anclosed or encapsulated:
linear/square toot
boiler,breecMnp,duct,tank surlaa9 coalmys _�S� '"Vy;a• solid ura;ipe insulation...... /
caruQated or Owed A4m p;O rresuiavo n. Z,gl #'s4; oQ cemerd...... .. ...... ..
spay-on fireyroohn0..... ......
Goths,worm,abrks.............. ti r arrb board wallboard.............
Oft(please dssaibe)................. _ _J
12. Describe the decontamination system($)to be used.
Remove asbestos inside ful_ 1 .;.;,.it"ainrnent, under negative
air pressure,
13. Describe the containerization/disposal methods to campy with 310 CMR 7.15 and 453 CMR 6,14(2)(8);
Wet down asbestos and doublebaq usi� six millimeter
marked and 1abledb
_asestos bads .—
14. For Emergency Asbestos Abatement Operations,the DEF and DLI officials who evaluated the emergency:
Arm ofarpoffidaf
task o(Aurnarrawn -- ------- — - WWI- _ ---------- - —
Jvme a txr asaaJ r,,N
Oa1e d n,nrorlrarron wa ger/
15. Do prevailing wage rates apply as per M,G L.c 14? ,2°.'. o, ?iA- r"to this project? 0 Yes )(No
Rev.02
Facility Description
1 Current or prior use of facility:
RESIDENCE
2. Is the facility owner-occupied residential with 4 units of-loss? /Ves --C--No
3. Facility Owner:
AOW
f\ 1Ov �0 q
QITAAV I+P axle Telephone
4. Facility's Owner's On-She Manager.
ci170w"
5. General Contractor,
p /town /V/A
tY 4119-lode
contractots W64013 comp.Insurer Pwcy I EXP.0810
6. What is the size of the facility?2510 10(sq ft) of floors)
Asbestos Transportation and Disposal
1. Transporter of as beslos-contain in g waste material tiom s4e to temporary storage she(If necessary)to final disposal she:
ASBESTOS MAN REMOVAL Co. 6 REVERE RD
AWfW
QUINCY, MA 02169 ( 617 ) 471 -6380
?4-:Ixw TNephan
2. Transporter of asbestos-containing waste material fm;r removall temporary storage site to final disposal site:
JOB ROLLOFF' TRANSPORT CO. P.O.B. 6037
Nan*
CHELSEA, MA 02150 (617 ) 387-1495
Note:Transfer
stations must 3. Refuse transfer station and owner(If applicable),
comply with the
SON waste N/A
Division regula- —------------
NOW AX-Im
bons 310 CMR
1A00
CIWTO- 10 wnr TOO"
4. Final Disposal Site:
CT Vq //Q V")
I I I
zim Mime i
aWn Al"
Al 9- c, ti, i , I , )
f �Ij
Aft=
V9
W11TO" lip C" r1ww"M
0 Cerfmcstioll
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.
PAUL ILACQUA
Sig In DO
Md#.Contractor
must 4n this OWNER A .M.R . CO. 617 ) 471 -6380
form for DO
nosk8tion
6 REVERE RD -,,UINCY, MA 02169
Add=
Fee exempt(City,Town,district,municipal hokis,;;ig owner-occupied residential of four units or less)?/yes 0 no
-I ) 6 q(4
Sticker I from front of toren):