HomeMy WebLinkAboutMiscellaneous - 32 SECOND STREET 4/30/2018 (2) 32 SECOND STREET
210/030.0-0029-0000.0
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N,Orl PICATION OP ASBESTOS WORK ,
(in accordance with the provialone of N.C.L. e. 149, §6•-6r and 45) CMR 6.12) '
A1l section# of this fore must be completed !n order to comply vltb
the ,notiflcatlon requirements of 4SJ• Ct1R 6.l9
TEN DAY PRIOR NOUPICATION•IS R,OVIPED OP ANY AMr6HENr Pgwrcr � t
GREATER MAN.MREB (31.LINEAR OR some-xBBr. �V
DLI PIL# NUHB61t2ei- 1O:S?',7Y
contractor performing project as�C w1J/,:.�N�1R►� .Lloenae 'I
Do prevailing rates of wages apply _to•this project as required
under H.C.L c. 149,'§26, 21 or 271'7 (circle one) Y83 ' NO
Address of_Projects
Building Name (it any)
Street. Address ��Ia Seu'�►� .. •
city— . Sip
project type (circle ona)#1, bBNOL.[4'ION ONOVA11109 1 REPAIR OTHER `
' If •Other. selected, please explain'
1 .01.,!••."A it:1,i, r .:11 i,l. , , .. • 1 i ..
Asbestos Activity 1(circle�one)i,l8NCllPSULArrON . .,,.1•� ' " ASSOCIATED PROVtcr "
t
• 1 � ENCLOSURE � NOVAL •� . . "•,'
Indicate amount oft Asbestos surface on pipes or ducts 7_ �' � LIN6AR.,rBBr
OR
asbestos surface on structures other than pipes or ducts ,
to be removed, enclosed- or encapsulated. ! `/O somas rssr
Start date S��l l [ _ am _ _ Iu^r,._- weekends?
completion bate
project Supervisor Name t114r14L'LT1 G-ouLeTr6 _ Certlflcate / 5 0 � 215� _
Asbestos Analytical Lab Namellt'Y�1 +n1&-,e,-Ie `1aalyS,SCertiflcat6�/' ��?UUoc��
1
Hace 6 Address of disposal 8lte(a) J_Vt4utwll T,O PPOIL blopri LL,
1
Is asbestos contract written or.
contractor'# Morker�,
! ' Fo11cy Number
racillty Owner k,7 f
Address 3
city State zip
Description. of work practices to be followedi__ l�
C� P p , /x/1!4 c / rI oL✓
5-3
Description of decontamination systems) to be. used
..9
Description of handling/disposal methods to comply with/J459 CUR 6.14(2) (71
Name and address of' transportet(s) If other- than the .asbestos contractor#
s
the undersigned hereby states, under the penalties of perjury, that he/she has
read and understood the .commonwealth of Massachusetts Regulations for the
Removal, Containment or dncapsulatlon of Asbestos, 459 elan 6.000. and that' the
Information contained In this notification In true and correct to the best of
his/her knowledge and belief• , 7
I
Dace .2 011; !�/ Slfined#
Titter
company: G�Z
please return this form tot
Asbestos Control Technical Servlces _
Department of Libor and Industries
Division of Industrial Safety
100 Cambridge Street, froom 1101
Boston, MA 02202-- ---
0049AI2
4- �9
&"A" CIA" V-64"! :1iY4"M ► a�,�roa�alawsl,� j
1XV, vim
w � NOTIFICATION OF ASBESTOS WORK
(Ili accordance j.ith the, provisions of N.G.L. C. 149, §6-6F and 453 CMR 6.12)
All sections of this form crust be completed hr-order to comply with
the notification requirements of 453 CMR 6.12
TEN DAY PRIOR NOTIFICATION IS REQUIRED OF ANY ABATEMENT PRa7ECT t.
CRBATBR TSAR TARES (3) LINEAR OR SQUARE FSST
i
DLr PILE Nunn 14' II& / J 21Z6-) _
7 . ir�. if.7ir�iiiLr License'# AC000001
NOWS'nel:
of wages apply to this project as required q.
vmlor K.C.L c. 149, 926, 27 or 27PP (circle one) YES �ND�
Address of Project
Building Name (if any) BLDG. 20, 30, 34, 34A, 37, 70 AND BUTLER HOUSE
Street Address AT 9_T TECHNOLOGIES, INC. 1600 OSGOOD STREET .•
City NORTH ANDOVER. MA Zip 01845
Project type (circle one): DSNOLITION r RENOVATION REPAIR OTHER
If •Other• selected, please explain
Asbestos Activity: (circle one): ENCAPSULATION ASSOCIATED PROJECT
ENCLOSURE RSKOVAL
Indicate amount of: asbestos surface on pipes or ducts AEPROX Spill P
FITTIAIM •• •
OR
asbestos surface on structures ether than pipes or ducts
to be removed, enclosed or encapsulated sQUARN PsBT
Start date 911191 am 7:00 pm 3:30 weekends? VES
Completion Date 4/30/91
Project Supervisor Name JAMES TOBIN Certificate N _�F)149�4_
Asbestos Analytical Lab Name CERTIFIED FNGINEEgTNG Certificate / AAOOOnn9
Name 6 Address of disposal site(s)_ SAWYER ENVIRONMENTAL, 358 EMERSON MILL ROAD,
HAMPDEN, MAINE ^rh"
0049a/l
r►
i
�4
.A .asbestos contract written or verbal?
Contractor's Workers Compensation Insurer
NA TONAL U,ti'ION FIRE INSURANCE
dt Policy Number WC-1128831
Facility Owner ....AT 9 T TECH OLOGIES INC.
Address I45 MR._ HOPE. CHURCH ROAD
City MCCLEANSVTLLE State NC Zip 01845
Description• of work practices to be followed: IN ACCORDNACE WITH 453 CMR 6. 14
Descripticn of decontamination system(s) to be used
REFER TO S 'TION 453 6. 14 (2)---(8)
Description of handling/disposal methods to comply with 453 CMR 6.14(2) (g)'
WETTED ASBESTOS WILL BE DOUBLE BAGGGED LABELLED AND STROED IN AN ON SITE. . .. ,
DUMPSTER PENDING TRANSFER TO FINAL DISPOSAL SITE.
Name and address of transporters) if other than the asbestos contractor:
CHEMICAL RECOVERY INC. _
197 PORTLAND STREET BOSTON MA 02114
The undersigned hereby states, under the penalties of perjury, that he/she has
read and understood the Commonwealth of Massachusetts Regulations for the
Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00, and that the
Information contained in this notification is true and correct to the best of
his/her knowledge and belief.
Date 1/8/91 Signed: Z i
Title: BRANCH MANAGER
Company: ACandS. INC. {
Please return this form to:
Asbestos Control Technical Services I
Department of Labor and Industries
Division of Industrial Safety i
100 Cambridge Street, Room 1101
Boston, MA 02102
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MASSACHUSETTS M(ISSACHU [TS
FIRE lNCIDE/v [ KEPURl1:1 (.1 n exp 1 date I day Warm tmiarry tmitime in seryl
STAlE F{HE MwH�H�L
A | @IIXXKX 4452
|
situation found | | action taken | | mutual aid-----'|
B | `
|
' ' ^"=" property / / ignition racxor | |
C |
|
*,;.,�-.'�.!'�,..�.);..:-,.,.).'-.Q.!.',.!.-....,'.-..�:).g.:!.:.Q.!','�,.'..--�.'.,.!.�..'.'--..(.:.'!.I�*.�.Qlli
| correct address | zip cod , | census---\
D |
| | occup. name last, first, mi } t el ephon~ | roox/ or' p----|
E |
|
| | W
owner name last first i | address ---'
, , m a ress | telephone |
F 1
|
| | method of alarm | | district | shift | no. alarms |
G |
Ii, |
| | #fire service | #tani�ers | #eng ines | #aerial �p � | # other hiclesl
H |
____-|-
| hazardous mat erial | substance - -�-------------- —
| special equip used |
|
|
. .."m"=. s of injuries / number or fatalities | rescues !
I |
i
| mobile property | | vehicle stolen ? | estimated total dollar i
J |
!
1-insurance company
/ total insurance | claim paid |
|
| | year � make | model | color | lic �no | vin# ---|
|
| | if equip involved | year | make } mo �
oel / serial no |
|
| area of origin 1 equip inv in
K | -
nition
I form of heat ignition | material ignited ! form � | type / |
L |
| method of extinguishment | | level of fire origin | |
M |
| numbers of stories � | construction type | |
|
| extent of flame damage | | extent of smoke damage --------- i
N |
\ detector performance | | sprinkler
--------|
P |
. if ~..""= sp =a" ' material generating / form | | type | |
| beyond room | most smoke : | } 00 } | NQ |
Q |
R | weather conditions |
|
| -------------------- | entries contained �
in this report are intended for |
| | The sole use of the state fire marshal. Estimat- |
| | ions & evaluations made herin represent "MOST |
| I LIKELY" & "MOST PROBABLE" cause & effect. Any |
| | representation as to the conditions outside the |
| | State Fire Marshals Office is neither intended nor |
| member making report | implied |
|
CHECKLIST FOR CARBON MONOXIDE
Location of Incident: ate of incident-- I
QUICK CHECKLIST OF OCCUPANTS
Headache yes no Fatigue yes no
Nausea yes no Dizziness yes no
Confusion yes no /
Are any members of the household feeling ill? yes no
Do the residents feel better away from the house? yes no:
Since the detector's alarm went off, what have you done? /
Shut- off carbon monoxide sources yes no V
If yes which sources
Let in fresh air? yes no
If yes how did you let the air in
How long did you let the air in
PPM reading ambient outside the dwelling 040
Highest PPM reading in the dwelling
Carbon monoxide detector present? yes no
If yes list the number of detetors locations and make, and serial number of each below.
I DO
2.
3.
4.
Which detector(s) by number above activated?
SOURCE CHECKLIST LOCATION PPM READING
Chimney clogged flue, blocked opening
Fireplace(s) Natural gas, LPG, Wood(indicate type for each fireplace)
Gas Appliance (if Gas Company on Scene they can perform this check)
(IF MORE THAN 1 OF THE FOLLOWING APPLIANCES LIST EACH ADDITIONAL
ON THE COMMENTS PAGE WITH ITS LOCATION, AND PPM READING)
refrigerator
stove _ CSO S
vent over stove
clothes dryer
water heater —�– 00
furnace _tea Z
Oil burner
car garage
Entranceway from garage to house
Name of individual operating the CO monitor tt , –T,-T Chi JiL(67
Person completing the Checklist